warfarin and Obesity--Morbid

The objective of this review was to provide dosing recommendations for percentage change in weekly warfarin dose and rates of thrombotic and bleeding events in patients requiring long-term warfarin therapy after bariatric surgery.. A comprehensive literature search of PubMed (through April 5, 2021), Cochrane Library, and Google Scholar (through April 5, 2021) databases was completed using the keywords warfarin OR vitamin k antagonist AND bariatric surgery.. Retrospective studies and matched-cohort studies evaluating preoperative and postoperative use of warfarin after bariatric surgery for obesity were considered. Weekly dose defined as sum of daily doses of warfarin for 7 consecutive days was a required outcome to be considered in this review. Patients were excluded from review if post-operative dosage change was not reported.. Six studies were included with a total of 160 patients who met the criteria. A decrease in average warfarin dose was seen in all studies, with the largest decrease occurring at 1 month postsurgery followed by an upward trend toward baseline about 90 days postsurgery. While thrombotic events were observed in none of the patients, there was an increased risk of bleeding in patients, particularly in those who underwent roux-en-y gastric bypass (RYGB) surgery.. The study provides a specific warfarin dosing titration regimen, as well as embolic and bleed risk in post-bariatric surgery population.. Clinicians may consider lowering warfarin weekly dose by about 25% immediately postsurgery, with doses approaching closer to baseline about 90 days postsurgery.

Topics: Anticoagulants; Bariatric Surgery; Gastric Bypass; Hemorrhage; Humans; Obesity, Morbid; Retrospective Studies; Treatment Outcome; Warfarin

Oral anticoagulants are crucial for preventing systemic thromboembolism in atrial fibrillation (AF), with guidelines preferring non-vitamin K antagonist oral anticoagulants (NOACs) over vitamin K antagonists (VKAs) in the general AF population. However, as NOACs are administered in fixed doses, concerns of unintentional underdosing in morbidly obese patients and unintentional overdosing in underweight patients have emerged. Therefore, a critical appraisal of the benefit-risk profile of NOACs in AF patients across the body weight spectrum is needed.. The benefit-risk profile of NOACs seems preserved in (morbidly) obese AF patients and patients with low body weight. However, more data are needed on underweight AF patients (BMI < 18.5 kg/m

Topics: Administration, Oral; Anticoagulants; Atrial Fibrillation; Fibrinolytic Agents; Hemorrhage; Humans; Obesity, Morbid; Stroke; Thinness; Warfarin

Direct oral anticoagulants (DOACs) have been increasingly preferred over warfarin; however, The International Society of Thrombosis and Hemostasis recommended avoiding the use of DOACs in morbidly obese patients (body mass index >40 or weight >120 kg) because of limited clinical data.. Are DOACs effective and safe in morbidly obese patients with nonvalvular atrial fibrillation (NVAF).. We performed a comprehensive search for published studies indexed in PubMed/MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials that evaluated the efficacy and safety of DOACs in morbidly obese patients with NVAF.. Information on patient characteristics, comorbidities, primary anticoagulation indications, pharmacologic treatment, and outcomes were collected. The primary outcome of interest was stroke or systemic embolism (SSE) rate. The secondary outcome was major bleeding (MB).. A total of 10 studies including, 89,494 morbidly obese patients with NVAF on oral anticoagulation therapy (45,427 on DOACs vs. 44,067 on warfarin) were included in the final analysis. The SSE rate was significantly lower in DOACs group compared with warfarin group [odds ratio: 0.71; 95% confidence interval (CI): 0.62-0.81; P < 0.0001; I2 = 0%]. MB rate was also significantly lower in DOACs group compared with the warfarin group (odds ratio: 0.60; 95% CI: 0.46-0.78; P < 0.0001; I2 = 86%). On subgroup analysis, SSE and MB event rates were significantly lower in rivaroxaban and apixaban than warfarin; however, dabigatran showed noninferiority to warfarin in SSE rate but superiority in the safety outcome.. Our meta-analysis demonstrated that DOACs are effective and safe with statistical superiority when compared with warfarin in morbidly obese patients. Large-scale randomized clinical trials are needed to further evaluate the efficacy and safety of DOACs in this cohort of patients.

Topics: Administration, Oral; Anticoagulants; Atrial Fibrillation; Dabigatran; Humans; Obesity, Morbid; Retrospective Studies; Rivaroxaban; Stroke; Warfarin

Bariatric surgery has emerged as a therapy for obesity and the associated comorbidities. Obesity has been shown to be a risk factor for atrial fibrillation as well as venous thromboembolism, both of which are conditions that warrant anticoagulation. There is significant underrepresentation of the morbidly obese population in prospective trials that evaluated direct oral anticoagulants and vitamin K antagonists in atrial fibrillation and venous thromboembolism. We aim to review all the available data that assessed these oral anticoagulants in the morbidly obese population (body mass index >40 kg/m

Topics: Anticoagulants; Atrial Fibrillation; Bariatric Surgery; Factor Xa Inhibitors; Humans; Obesity, Morbid; Stroke; Venous Thromboembolism; Warfarin

The International Society of Thrombosis and Haemostasis recommends warfarin therapy over direct oral anticoagulants (DOACs) in patients with a body mass index >40 kg/m

Topics: Administration, Oral; Anticoagulants; Atrial Fibrillation; Hemorrhage; Humans; Obesity, Morbid; Pulmonary Embolism; Stroke; Warfarin

Numerous factors are well documented to affect the response to vitamin K antagonists (VKA), including dietary vitamin K, other drugs, age, pharmacogenetics, and disease states. Body weight is perhaps not as well known as a variable affecting VKA dose. Our aim was to review the literature regarding body weight and VKA dose requirements.. We reviewed the English-language literature via PubMed and Scopus using the search terms VKA, warfarin, acenocoumarol, phenprocoumon, fluindione, AND body weight.. Among 32 studies conducted since the widespread use of the international normalized ratio, 29 found a correlation with body weight or body surface area and VKA dose requirement. Warfarin was evaluated in 27 studies and acenocoumarol, phenprocoumon, or fluindione were assessed in 5 investigations.. Because of varying study methodologies, further study is warranted. Based on current evidence, clinicians should include body weight, along with other established variables when dosing VKA. Most important, obese and morbidly obese patients may require a 30% to 50% increase with the initial dosing of VKA.

Topics: Acenocoumarol; Anticoagulants; Body Weight; Comorbidity; Drug Dosage Calculations; Humans; Obesity; Obesity, Morbid; Phenindione; Phenprocoumon; Vitamin K; Warfarin

Warfarin (Coumadin)-induced necrosis of the skin is an unusual condition associated with the administration of warfarin. The necrotic lesions appear suddenly and are extremely painful. Single or multiple lesions develop in a distinct pattern. A hypercoagulable state created early in the course of warfarin administration is most likely responsible for warfarin-associated necrosis. Functional and inherited low levels of proteins C and S are found in some patients. The differential diagnosis of warfarin necrosis is of interest to the plastic surgeon. The condition may mimic purpura fulminans, necrotizing fasciitis, microembolization, breast cancer, and decubitus ulcers. Early recognition and treatment are essential to avoid significant and prolonged morbidity. Mortality has also been reported. We present 2 cases of warfarin-induced necrosis and a review of the literature.

Topics: Diagnosis, Differential; Female; Humans; Male; Middle Aged; Necrosis; Obesity, Morbid; Priapism; Skin; Warfarin

Achieving therapeutic anticoagulation with warfarin is complicated by substantial inter-patient and intra-patient variability with numerous factors known to influence dose requirements. Obesity is one factor for which there remains no study to date investigating its initial effect on warfarin response assessed by INR, stratified by BMI category in hospitalized patients. To compare initial warfarin response between obese and non-obese patients by evaluating average daily dose (ADD), time required to attain therapeutic INR, and mean discharge dose (MDD), stratified by BMI category. A retrospective review was conducted to evaluate initial warfarin response in hospitalized patients of different BMI categories initiated on warfarin with ≥4 consecutive days of therapy and managed by pharmacy dosing service. 211 patients were included (10 underweight, 45 normal weight, 48 overweight, 71 obese, 37 morbidly obese). Across BMI categories, the percentage of patients attaining therapeutic INR prior to discharge differed (p = 0.0004) with 71.1 % of normal weight therapeutic compared to 42.3 % of obese and 38 % of morbidly obese. Within BMI categories, when comparing ADD between patients therapeutic and subtherapeutic at discharge, no differences were observed, except among overweight patients (5.6 ± 0.3 vs. 7 ± 0.4 mg, p = 0.0143). Compared to normal weight, obese and morbidly obese required a significantly longer median time to achieve therapeutic INR (8 and 10 days vs. 6 days) and a higher ADD (6.6 ± 0.3 and 7.6 ± 0.5 vs. 5 ± 0.3 mg) and MDD (6.7 ± 0.5 and 6.7 ± 0.7 vs. 4.4 ± 0.5 mg). Compared to normal weight, obese and morbidly obese patients had a decreased initial response to warfarin.

Topics: Aged; Anticoagulants; Body Mass Index; Female; Humans; In Vitro Techniques; International Normalized Ratio; Male; Middle Aged; Obesity, Morbid; Thinness; Warfarin

Obesity is a known risk factor for venous thromboembolism (VTE) and poses a unique set of challenges in anticoagulation management. We report a 10-year experience of VTE management in morbidly obese patients. We conducted a retrospective analysis of VTE presentations to Northern Health, Victoria, Australia, from January 2011 to December 2020, with median follow-up of 44 months. Morbidly obese patients (defined as weighing > 120 kg) were compared to those ≤ 120 kg. Patients with active malignancy were excluded. 194 VTE cases with weight > 120 kg were compared to 2168 cases weighing ≤ 120 kg. Patients > 120 kg were more likely to present with unprovoked VTE (59.3% vs. 45.2%, p < 0.001) and major VTE (74.7% vs. 67.4%, p = 0.028). Overall, patients > 120 kg were more likely to develop VTE recurrence after anticoagulation cessation (7.80 vs. 3.92 per 100-patient-years, HR 1.97, 95%CI 1.29-3.00), while there were no significant differences in major bleeding or 30-day all-cause mortality. There were no significant differences in outcomes in patients > 120 kg treated with warfarin compared to direct oral anticoagulants (DOAC), or when comparing those treated with an uncapped (1 mg/kg BD) vs. capped (< 1 mg/kg) enoxaparin dosing regimen. Morbid obesity is associated with increased clot burden at presentation and VTE recurrence following anticoagulation cessation, without significant differences in bleeding compared to those ≤ 120 kg. There were no significant differences in morbidly obese patients' outcomes when treated with warfarin or DOAC, or when treated with an uncapped or capped enoxaparin dosing strategy. Larger randomised controlled trials evaluating the safety of DOACs and different enoxaparin dosing strategies in patients > 120 kg are warranted.

Topics: Administration, Oral; Anticoagulants; Enoxaparin; Hemorrhage; Humans; Obesity, Morbid; Retrospective Studies; Venous Thromboembolism; Warfarin

Approximately 3% of patients undergoing metabolic and bariatric surgery (MBS) are receiving chronic anticoagulation therapy (CAT) prior to operation. The management of these patients is complex, as it involves balancing the potential risk of thrombosis against that of bleeding. Our primary objective is to assess the long-term bleeding risk in patients undergoing MBS. We also aim to observe the trends in anticoagulant dosing after MBS.. A single-center retrospective review of patients who underwent either primary Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) with preoperative CAT between 2008 and 2022 was performed. Data on baseline demographics, indication for anticoagulation, type of CAT, and dosing were collected. Events of bleeding and the CAT at event were subsequently evaluated.. A total of 132 patients (82 RYGB and 50 SG) initially on CAT were identified, with atrial fibrillation being the most common indication. Incidence of long-term bleeding was significantly higher in the RYGB group (18.3%) compared to the SG group (4%) (p = 0.017) over a total of 5.2 ± 3.8 years. Bleeding marginal ulcer (MU) was the most common cause of bleeding in the RYGB group (13.4%). 84.2% of all bleeding events occurred in patients on chronic Warfarin therapy.. Long-term CAT is associated with an increased risk of bleeding in RYGB patients, particularly MU bleeds. Patients on CAT seeking MBS should be counseled regarding this risk and potential implications. Direct-acting oral anticoagulants offer promise as an alternative to Warfarin in these patients; further research is necessary to better understand their safety.

Topics: Anticoagulants; Bariatric Surgery; Gastrectomy; Gastric Bypass; Hemorrhage; Humans; Obesity, Morbid; Retrospective Studies; Treatment Outcome; Warfarin

Direct oral anticoagulants such as dabigatran are the preferred anticoagulant in treating atrial fibrillation (AF) patients due to their effectiveness and safety. Whether this applies to severely obese patients needs to be determined.. To compare the effectiveness and safety of dabigatran with warfarin among AF patients with severe obesity.. Retrospective cohort study.. Not applicable.. Primary effectiveness outcome was composite thromboembolism including transient ischemic attack, ischemic stroke, or systemic embolism. Primary safety outcome was composite bleeding including gastrointestinal bleeding, intracranial bleeding, or other bleeding. Secondary outcomes included the individual outcomes and all-cause mortality. Propensity score matching (PSM) was performed to create a 1:1 matched cohort and Cox proportional hazards model was used to estimate the hazard ratio (HR) of each outcome for dabigatran users compared to warfarin users.. A total of 6848 patients receiving either dabigatran or warfarin were identified. In a 1:1 matched cohort, dabigatran users had a HR of 0.71 (95% confidence interval (CI): 0.56-0.91) for composite thromboembolism, a HR of 1.24 (95%CI: 1.07-1.42) for composite bleeding, and a HR of 0.57 (95% CI: 0.45-0.71) for all-cause mortality when compared to warfarin users.. Among AF patients with a BMI >40kg/m

Topics: Administration, Oral; Anticoagulants; Atrial Fibrillation; Cohort Studies; Dabigatran; Gastrointestinal Hemorrhage; Humans; Obesity, Morbid; Retrospective Studies; Stroke; Thromboembolism; Treatment Outcome; Warfarin

Rivaroxaban is a first-line option for the management of venous thromboembolism (VTE). However, limited data are available regarding its effectiveness in morbidly obese patients.. To evaluate rates of thrombosis and bleeding in morbidly obese patients receiving rivaroxaban or warfarin for VTE.. A multicenter, retrospective cohort study was conducted to compare rates of bleeding and thrombosis in patients receiving rivaroxaban versus warfarin for acute VTE. Patients were included if they were older than 18 years and had a body mass index (BMI) greater than 40 kg/m. A total of 1281 patients were identified for acute VTE and were included in this study with 487 patients receiving rivaroxaban and 785 receiving warfarin. The average cohort age was 57.6 ± 14.6 years, and the average weight was 136.4 ± 27.2 kg. After controlling for confounding factors, the use of rivaroxaban was not associated with an increased hazard of VTE events when compared with warfarin (hazard ratio [HR] = 0.69, 95% confidence interval [CI]: 0.42-1.08,. No difference was observed in obese patients with weight >120 kg or BMI >40 kg/m

Topics: Adult; Aged; Anticoagulants; Factor Xa Inhibitors; Hemorrhage; Humans; Middle Aged; Obesity, Morbid; Retrospective Studies; Rivaroxaban; Venous Thromboembolism; Warfarin

Prior observational studies suggest rivaroxaban is safe and effective among patients with morbid obesity who suffered a venous thromboembolism (VTE) event, but existing data are more limited in the broader population of VTE patients with obesity. This study assessed VTE recurrence, major bleeding, healthcare resource utilization, and healthcare costs among VTE patients with obesity who received rivaroxaban versus warfarin. VTE patients with obesity who initiated rivaroxaban or warfarin after a first VTE (index date) were identified from the IQVIA PharMetrics® Plus database (01/02/2011-09/30/2019). The follow-up period spanned from the index date until health plan disenrollment, end of data availability, cancer diagnosis/treatment, end of the 12 month post-index period, or (for the analysis of major bleeding) anticoagulant discontinuation or switch. Patient characteristics were balanced using inverse probability of treatment weighting. The weighted rivaroxaban (N = 8666) and warfarin cohorts (N = 5946) were well balanced (mean age = 51 years, females = 52%). Over a 9.6 months mean observation period, rivaroxaban users had a significantly lower risk of VTE recurrence [7.0% vs. 8.2%, HR(95% CI) = 0.85(0.75;0.97)] and a similar risk of major bleeding [4.1% vs. 3.6%, HR(95% CI) = 1.11(0.89;1.37)] relative to warfarin users at 12 months. Relative to warfarin users, rivaroxaban users had significantly fewer all-cause outpatient visits [RR(95% CI) = 0.71(0.70;0.74)]. The higher pharmacy costs incurred by rivaroxaban recipients (cost difference = $1252) were offset by lower medical costs (cost difference = - $2515, all p < 0.05) compared with warfarin recipients. Our findings suggest that rivaroxaban is safe and effective versus warfarin, and associated with lower medical costs among VTE patients with obesity.

Topics: Anticoagulants; Factor Xa Inhibitors; Female; Health Care Costs; Hemorrhage; Humans; Middle Aged; Obesity, Morbid; Retrospective Studies; Rivaroxaban; United States; Venous Thromboembolism; Warfarin

Despite evolving evidence, the use of direct oral anticoagulants (DOACs) in patients with extremes of body weight remains controversial. This study aimed to measure the impact of DOACs compared to warfarin on safety and efficacy outcomes in extreme body weight patients. This multi-center, health system, retrospective study examined the outcomes of patients with all body weights and extreme body weights prescribed a DOAC (rivaroxaban, apixaban, dabigatran, edoxaban) or warfarin for atrial fibrillation or venous thromboembolism over a 9-year period. The primary outcome was a composite of thromboembolism, symptomatic recurrent VTE, or severe bleeding; analyzed by pre-determined BMI cutoffs. A total of 19,697 patients were included in the study: 11,604 in the DOAC group and in the 8093 in the warfarin group. 295 patients were underweight and 9108 patients were pre-obese to obese class 3. After adjusting for potential confounders, warfarin patients had higher odds of experiencing the composite outcome compared to DOAC patients (OR 1.337, 95% CI 1.212-1.475). Additionally, obese patients were 24.6% more likely to experience the outcome compared to normal BMI patients. Adjusted modeling showed that warfarin patients experienced higher bleed rates compared to DOAC patients (OR 1.432, 95% CI 1.266-1.620). Obese patients were less likely to be diagnosed with a bleed (OR 0.749, 95% CI 0.658-0.854), and underweight patients were more likely to be diagnosed with a bleed (OR 1.522, 95% CI 1.095-2.115) compared to normal BMI patients. In conclusion, DOACs for atrial fibrillation or VTE in patients with extreme body weights appear safe and effective when compared to warfarin.

Topics: Administration, Oral; Anticoagulants; Atrial Fibrillation; Hemorrhage; Humans; Obesity, Morbid; Retrospective Studies; Rivaroxaban; Stroke; Thinness; Venous Thromboembolism; Warfarin

Topics: Atrial Fibrillation; Body Mass Index; Factor Xa Inhibitors; Humans; Meta-Analysis as Topic; Obesity, Morbid; Patient Selection; Rivaroxaban; Treatment Outcome; Venous Thromboembolism; Warfarin

Studies on the use of direct oral anticoagulants (DOACs) in obese patients are limited. Current guidelines advise against DOAC use in patients with a body weight more than 120 kg or body mass index higher than 40 kg/m. Retrospective matched cohort study.. Integrated delivery system of 40 academic, community, and specialty hospitals.. A total of 1840 adults with a primary admission diagnosis of acute VTE who received a DOAC (apixaban, dabigatran, or rivaroxaban [632 patients] or warfarin [1208 patients]) while hospitalized between January 1, 2011, and October 1, 2015, and who had a body weight more than 100 kg and less than 300 kg, were included. Patients in the warfarin group were matched in a 2:1 ratio to patients who received a DOAC based on history of VTE, chronic kidney disease, race, and age.. The primary outcome was recurrence of VTE within 12 months of the index admission date. Secondary outcomes included occurrence of pulmonary embolism (PE) and deep vein thrombosis (DVT) events separately within the study time frame, as well as bleeding within 12 months of the index admission date. No significant difference in the recurrence of VTE was observed between patients who received a DOAC compared with those who received warfarin (6.5% vs 6.4%, p=0.93). Likewise, no significant differences in the occurrence of PE and DVT were seen between the DOAC- and warfarin-treated patients (3.7% vs 3.8%, p=0.94, and 3% vs 3.5%, p=0.56, respectively). Bleeding occurred in 1.7% and 1.2% of patients in the DOAC and warfarin groups, respectively (p=0.31).. To our knowledge, this is the largest clinical study to date showing that patients with obesity can be treated effectively and safely with a DOAC compared with warfarin for acute VTE. Thus DOACs should be considered a reasonable alternative to warfarin for treatment of acute VTE in obese patients.

Topics: Administration, Oral; Aged; Anticoagulants; Cohort Studies; Dabigatran; Female; Humans; Male; Middle Aged; Obesity, Morbid; Pulmonary Embolism; Pyrazoles; Pyridones; Retrospective Studies; Rivaroxaban; Treatment Outcome; Venous Thromboembolism; Warfarin

Anticoagulation management is challenging in bariatric surgery patients, due to altered gastrointestinal anatomy and potentially reduced absorption. Few studies have evaluated clinical outcomes in this population. The objective of this study was to compare the efficacy and safety of oral anticoagulants in patients with and without a history of bariatric surgery. A retrospective, matched cohort study was conducted, utilizing data from the OptumLabs Data Warehouse. Patients ≥18 years old, with nonvalvular atrial fibrillation (NVAF), and treated with an oral anticoagulant between January 1, 2010 and December 31, 2018 were included. Outcomes were compared between bariatric and nonbariatric surgery patients. Secondary analysis compared warfarin to the direct oral anticoagulants (DOAC) in the bariatric cohort. The primary efficacy outcome was the rate of ischemic stroke and systemic embolism and the primary safety outcome was major bleeding. A total of 1,673 bariatric surgery and 155,619 nonbariatric surgery patients were identified. There was no significant difference in the rate of ischemic stroke or systemic embolism (0.83 vs 1.32 per 100 person years; Hazard ratio [HR] 0.62, 95% confidence interval [CI] 0.31 to 1.22; p = 0.17) or major bleeding (5.30 vs 4.87 per 100 person years; HR 1.05, 95% CI 0.80 to 1.37; p = 0.73) between bariatric and nonbariatric surgery patients. In bariatric surgery patients alone, efficacy and safety were similar with warfarin compared with the DOACs. Results of this study suggest that bariatric surgery patients are not at an increased thrombotic or bleeding risk when using oral anticoagulants for NVAF. DOACs may be a reasonable alternative to warfarin.

Topics: Administration, Oral; Aged; Aged, 80 and over; Anticoagulants; Atrial Fibrillation; Bariatric Surgery; Cohort Studies; Factor Xa Inhibitors; Female; Humans; Male; Middle Aged; Obesity, Morbid; Retrospective Studies; Stroke; Treatment Outcome; Warfarin

Topics: Factor Xa Inhibitors; Humans; Obesity, Morbid; Retrospective Studies; Rivaroxaban; Warfarin

Topics: Anticoagulants; Factor Xa Inhibitors; Humans; Obesity, Morbid; Retrospective Studies; Warfarin

Limited data exist on direct-acting oral anticoagulants in morbidly obese patients with venous thromboembolism (VTE). We compared clinical and health/economic outcomes with rivaroxaban versus warfarin for VTE treatment in morbidly obese patients.. This retrospective 1:1 propensity score matched cohort study analyzed data from 2 US claims databases. VTE patients initiating rivaroxaban or warfarin were identified who had diagnosis codes for morbid obesity (ICD-9:278.01,V85.4; ICD-10:E66.01,E66.2,Z68.4) 12 months pre- or 3 months post-initiation and followed ≥3 months. Intent-to-treat (ITT) and on-treatment (OT) analyses were conducted using conditional logistic regression and generalized linear models to compare recurrent VTE and major bleeding risks, healthcare resource utilization (HRU), and per patient per year (PPPY) costs.. In total, 2890 matched pairs of morbidly obese VTE patients initiating rivaroxaban or warfarin were identified. Risks of recurrent VTE (ITT: OR: 0.99; 95% CI: 0.85-1.14) and major bleeding (OT: OR: 0.75; 95% CI: 0.47-1.19) were similar for cohorts. Anti-Factor Xa laboratory measurement was performed on <1% of rivaroxaban cohort. Hospitalizations (OR: 0.86; 95% CI: 0.77-0.96) and outpatient visits (OR: 0.23; 95% CI: 0.10-0.56), were lower with rivaroxaban versus warfarin (ITT analysis). Average total medical costs PPPY were $2829 lower with rivaroxaban versus warfarin ($34,824 vs $37,653), mainly driven by hospitalization costs. Total healthcare costs (including pharmacy) were similar ($43,034 vs $44,565).. Morbidly obese VTE patients receiving rivaroxaban had similar risks of recurrent VTE and major bleeding versus warfarin. Rivaroxaban treatment yielded significantly less HRU and total medical costs, with similar total healthcare costs between groups.

Topics: Adult; Aged; Anticoagulants; Factor Xa Inhibitors; Female; Humans; Male; Middle Aged; Obesity, Morbid; Retrospective Studies; Rivaroxaban; Treatment Outcome; Venous Thromboembolism; Warfarin

The International Society of Thrombosis and Haemostasis recommends avoiding direct oral anticoagulants (DOACs) in morbidly obese patients with a body mass index (BMI) >40 kg/m. The objective of this study was to evaluate the efficacy and safety of DOACs in morbidly obese patients with atrial fibrillation or flutter.. A retrospective, single-center cohort study was conducted of patients older than 18 years, with BMI >40 kg/m. A total of 64 patients in each group were included in the study analysis. The incidence rate of ischemic stroke or TIA was 1.75%/year in the DOAC group compared with 2.07%/year in the warfarin group (rate ratio = 0.84; 95% CI = 0.23 to 3.14; P = 0.80). The incidence rate of major bleeding was 2.18%/year in the DOAC group, compared with 4.97%/year in the warfarin group (rate ratio = 0.44; 95% CI = 0.15 to 1.25; P = 0.11). Conclusion and Relevance: Apixaban and rivaroxaban may be considered as alternatives to warfarin for atrial fibrillation or flutter in morbidly obese patients. Dabigatran use in morbidly obese patients needs caution until further studies are conducted.

Topics: Administration, Oral; Adolescent; Adult; Aged; Aged, 80 and over; Anticoagulants; Atrial Fibrillation; Cohort Studies; Dabigatran; Drug Therapy, Combination; Female; Hemorrhage; Humans; Incidence; Male; Middle Aged; Obesity, Morbid; Pyrazoles; Pyridones; Retrospective Studies; Rivaroxaban; Stroke; Warfarin; Young Adult

There are limited data regarding clinical outcomes and healthcare resource utilization of direct oral anticoagulants (DOACs) in patients with atrial fibrillation (AF) who are morbidly obese (body mass index >40 kg/m. Using data from 2 US healthcare claims databases, we identified patients initiating rivaroxaban or warfarin who had ≥1 medical claim with an AF diagnosis, a diagnostic code for morbid obesity (ICD-9: 278.01, V85.4%; ICD-10: E66.01%, E66.2%, Z68.4%), and a minimum continuous enrollment of 12 months before and 3 months after treatment initiation. Patients were excluded if they had mitral stenosis, a mechanical heart valve procedure, an organ/tissue transplant, or an oral anticoagulant prescription prior to the index date. Rivaroxaban and warfarin patients were 1:1 propensity score matched. Conditional logistic regression was used to compare ischemic stroke/systemic embolism and major bleeding risk. Generalized linear models were used to compare healthcare resource utilization and costs.. A total of 3563 matched pairs of morbidly obese AF patients treated with rivaroxaban or warfarin were identified. The majority (81.4%) of patients in the rivaroxaban cohort were receiving the 20 mg dose. The rivaroxaban and warfarin cohorts were well balanced after propensity score matching. The risks of ischemic stroke/systemic embolism and major bleeding were similar for rivaroxaban and warfarin users (stroke/systemic embolism: 1.5% vs 1.7%; odds ratio [OR]: 0.88; 95% confidence interval [CI]: 0.60, 1.28; P = .5028; major bleeding: 2.2% vs 2.7%; OR: 0.80; 95% CI: 0.59, 1.08; P = .1447). Total healthcare costs including medication costs per patient per year (PPPY) were significantly lower with rivaroxaban versus warfarin ($48,552 vs $52,418; P = .0025), which was primarily driven by lower hospitalization rate (50.2% vs 54.1%; P = .0008), shorter length of stay (7.5 vs 9.1 days; P = .0010), and less outpatient service utilization (86 vs 115 visits PPPY; P < .0001).. Morbidly obese AF patients treated with rivaroxaban had comparable risk of ischemic stroke/systemic embolism and major bleeding as those treated with warfarin, but lower healthcare resource utilization and costs.

Topics: Anticoagulants; Atrial Fibrillation; Drug Costs; Factor Xa Inhibitors; Female; Follow-Up Studies; Humans; Incidence; Male; Middle Aged; Morbidity; Obesity, Morbid; Retrospective Studies; Rivaroxaban; Stroke; Survival Rate; United States; Warfarin

Topics: Administration, Oral; Anticoagulants; Factor Xa Inhibitors; Humans; Obesity, Morbid; Retrospective Studies; Warfarin

Because studies of direct oral anticoagulants in patients with venous thromboembolism and non-valvular atrial fibrillation have had minimal representation of morbidly obese patients (ie, body-mass index [BMI] ≥40 kg/m. We did a single-centre, retrospective analysis of chart data for all adult patients aged at least 18 years at Montefiore Medical Center (Bronx, NY, USA) with a BMI of at least 40 kg/m. We obtained data for 795 patients: 150 prescribed apixaban, 326 rivaroxaban, and 319 warfarin. In 366 patients prescribed an anticoagulant for venous thromboembolism, the incidence of recurrent venous thromboembolism was similar between the apixaban, rivaroxaban, and warfarin cohorts (1/47 [2·1%, 95% CI 0·0-6·3], 3/152 [2·0%, 0·0-4·2], and 2/167 [1·2%, 0·0-2·9], respectively; p=0·74). Incidence of major bleeding in this patient group was also similar between the treatment cohorts (1/47 patients on apixaban [2·1%, 95% CI 0·0-6·3], 2/152 on rivaroxaban [1·3%, 0·0-3·1], and 4/167 on warfarin [2·4%, 0·1-4·7]; p=0·77). In 429 patients prescribed an anticoagulant for atrial fibrillation, incidence of stroke was similar between the treatment cohorts (1/103 patients on apixaban [1·0%, 95% CI 0·0-2·9], 4/174 on rivaroxaban [2·3%, 0·1-4·5], and 2/152 on warfarin [1·3%, 0·0-3·1], p=0·71). In this patient group, major bleeding occurred in 3/103 patients on apixaban (2·9%, 95% CI 0·0-6·2), 5/174 on rivaroxaban (2·9%, 0·4-5·4), and 12/152 on warfarin (7·9%, 3·6-12·2); p=0·063. Time-to-event analyses showed that risk of all outcomes in patients with venous thromboembolism, and stroke and composite bleeding in patients with atrial fibrillation, were similar between the anticoagulant cohorts.. Our retrospective study provides further evidence of similar efficacy and safety between the direct oral anticoagulants apixaban and rivaroxaban, and warfarin in morbidly obese patients with atrial fibrillation and venous thromboembolism. These data, if confirmed in prospective studies, might enable patients with a BMI of at least 40 kg/m. None.

Topics: Adult; Aged; Anticoagulants; Atrial Fibrillation; Body Mass Index; Factor Xa Inhibitors; Female; Hemorrhage; Humans; International Normalized Ratio; Male; Middle Aged; Obesity, Morbid; Proportional Hazards Models; Pyrazoles; Pyridones; Recurrence; Retrospective Studies; Rivaroxaban; Venous Thromboembolism; Warfarin

Warfarin dosing after bariatric surgery may be influenced by alterations in gastrointestinal pH, transit time, absorptive surface area, gut microbiota, food intake, and adipose tissue.. The aim of this study was to describe trends in warfarin dosing after Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG).. Single academic center.. All patients chronically on warfarin anticoagulation before RYGB or SG were retrospectively identified. Indications for anticoagulation, history of bleeding or thrombotic events, perioperative complications, and warfarin dosing were collected.. Fifty-three patients (RYGB n = 31, SG n = 22) on chronic warfarin therapy were identified (56.6% female, mean 54.4 ± 11.7 yr of age). Of this cohort, 34.0% had prior venous thromboembolic events, 43.4% had atrial fibrillation, and 5.7% had mechanical cardiac valves. Preoperatively, the average daily dose of warfarin was similar in the RYGB group (8.3 ± 4.1 mg) and SG group (6.9 ± 2.8 mg). One month after surgery, mean daily dose of warfarin was reduced 24.1% in the RYGB group (P<.001) and 23.2% in the SG group (P = .002). At 12 months postoperatively, the required daily warfarin dose compared with baseline remained statistically different (RYGB: 6.8 ± 3.8 mg; SG: 6.1 ± 2.0 mg).. The warfarin dose is expected to be decreased by approximately 25% from preoperative levels after both RYGB and SG. Lower dose requirement within the first month after bariatric surgery is followed by a trend toward increased warfarin dose requirements, but remain less than baseline. Because dose requirements change constantly over time, frequent postoperative monitoring of the international normalized ratio is recommended.

Topics: Anticoagulants; Atrial Fibrillation; Bariatric Surgery; Drug Administration Schedule; Female; Gastrectomy; Gastric Bypass; Heart Valve Prosthesis; Hemorrhage; Humans; International Normalized Ratio; Laparoscopy; Male; Middle Aged; Obesity, Morbid; Postoperative Care; Preoperative Care; Retrospective Studies; Venous Thromboembolism; Warfarin

Topics: Gastrectomy; Gastric Bypass; Humans; Laparoscopy; Obesity, Morbid; Treatment Outcome; Warfarin; Weight Loss

Venous gangrene complicating deep vein thrombosis in the context of anticoagulation use in patients with gynecologic malignancy is rarely reported. We report an unusual presentation of venous gangrene of the lower limbs associated with warfarin therapy in a 53-year-old woman from the Cook Islands with an occult ovarian cancer.. A 53-year-old woman of Cook Islands origin presented with exertional dyspnea, rapid atrial fibrillation, bilateral lower limb edema, and painful digital ischemia of her hallux. She was on warfarin therapy for atrial fibrillation and had a stable therapeutic international normalized ratio. Bilateral proximal lower limb deep vein thrombosis and digital gangrene subsequently developed in the setting of a supratherapeutic international normalized ratio and platelet count depletion. Her warfarin was reversed and heparin therapy was commenced with resulting correction of her thrombocytopenia.. We would like to attract the attention of the reader to the potential hazard of the use of warfarin in patients with malignancy. In our case, we also demonstrated a predictive value of supratherapeutic international normalized ratio and platelet count depletion that could herald massive thrombosis and gangrene in a patient who was previously stable on warfarin therapy. Early recognition and prompt reversal of warfarin in these circumstances is essential to correct the unbalanced prothrombotic process that leads to extensive thrombosis and gangrene. The outlook of such cases remains dismal and results in extensive morbidity and mortality.

Topics: Anticoagulants; Atrial Fibrillation; Female; Gangrene; Heparin; Humans; International Normalized Ratio; Ischemia; Middle Aged; Obesity, Morbid; Ovarian Neoplasms; Thrombocytopenia; Toes; Ultrasonography, Doppler; Venous Thrombosis; Warfarin

Lehigh Valley Health Network (LVHN), a nonprofit tertiary care facility in Allentown, Pennsylvania, is an accredited American College of Surgeons Bariatric Surgery Center Network (ACSBSCN) Level 1 site performing 400+ bariatric procedures annually. Bariatric data submission began in April 2008. Complication review revealed that approximately 17 % of patients on chronic anticoagulation (warfarin) therapy preoperatively were readmitted with supratherapeutic international normalized ratios (INRs), postsurgical bleeding, anastomotic ulcer, or other intraluminal hemorrhage. Opinion level recommendations have been published regarding the adjustment of warfarin dosages post-bariatric procedures with no widespread consensus. Case series have been published detailing perioperative hemorrhage risk for bariatric patients on preoperative anticoagulation. Little data of post-discharge hemorrhage rates have been published. With increasing numbers of bariatric surgical procedures performed annually, there is a potential for developing serious coagulopathic complications in those patients who resume their anticoagulation therapy postoperatively.. Retrospective review of LVHN data from the ACSBSCN database was analyzed for 30-day readmissions due to documented extra- or intraluminal hemorrhage with INR and coagulopathy. Follow-up INR and warfarin doses were collected up to 6 months postoperatively.. Over a 3-year period, 38 patients undergoing bariatric procedures were identified as being on preoperative warfarin therapy. Six of 38 developed hemorrhage within 30 days. Two patients presented beyond 30 days with bleeding. Supratherapeutic INR was present in five of six readmitted patients. Mean INR was 5.8. Warfarin sensitivity was present in a statistically significant higher number of patients within 30 days of surgery. After 30 days, a resistance to warfarin was demonstrated.. Bariatric surgery patients taking warfarin are prone to coagulopathy in the early post-op period requiring vigilant monitoring to prevent supratherapeutic INR and corresponding risk of hemorrhage.

Topics: Adult; Anticoagulants; Drug Administration Schedule; Female; Gastric Bypass; Hemorrhage; Humans; International Normalized Ratio; Male; Middle Aged; Obesity, Morbid; Outcome Assessment, Health Care; Patient Discharge; Patient Readmission; Pennsylvania; Retrospective Studies; Risk Factors; Time Factors; Warfarin

Calciphylaxis is a rare, usually fatal vasculopathic disorder characterized by cutaneous ischemia and necrosis due to calcification of arterioles. Although calciphylaxis is most frequently associated with end-stage renal disease (ESRD) and secondary hyperparathyroidism, it has been reported infrequently among patients on warfarin. No standard treatment has been established for atypical calciphylaxis; however, a potentially beneficial treatment is hyperbaric oxygen therapy (HBOT). A high degree of clinical suspicion, early diagnosis, and understanding the pathophysiology of this disease promotes the optimal management of this extremely morbid and often fatal condition.. We present a 63-year-old Polynesian woman with biopsy-proven calciphylaxis in the absence of ESRD or elevated serum calcium levels while taking warfarin. Therapeutic dose enoxaparin was substituted for warfarin and she received 40 sessions of HBOT during which lower extremity ulcers resolved.. Warfarin has been implicated when calciphylaxis presents in an atypical fashion. No guidelines exist for treatment of atypical calciphylaxis in the setting of concomitant warfarin therapy. Up to 80% of calciphylaxis patients die within 1 year of diagnosis. Our patient was changed to low-molecular-weight heparin and received HBOT.. We present what we believe is the first case of atypical calciphylaxis thought to be attributable to warfarin treated with a therapeutic substitution of anticoagulant and HBOT leading to resolution of cutaneous lesions.

Topics: Anti-Bacterial Agents; Anticoagulants; Calciphylaxis; Calcium-Binding Proteins; Cellulitis; Combined Modality Therapy; Debridement; Diabetes Mellitus, Type 2; Extracellular Matrix Proteins; Female; Humans; Hyperbaric Oxygenation; Leg Ulcer; Matrix Gla Protein; Middle Aged; Obesity, Morbid; Risk Factors; Thrombophilia; Warfarin

The role of genetic polymorphisms and genetic testing in guiding warfarin dosing is discussed, as are the selection and monitoring of anticoagulant therapy for obese patients, patients with severe renal impairment, and patients with heparin-induced thrombocytopenia (HIT); case studies are used to illustrate each topic.. Genetic polymorphisms influence metabolism of and sensitivity to warfarin. People with certain ethnic backgrounds have a greater likelihood of having genetic polymorphisms that reduce warfarin dosing requirements and increase the risk of bleeding. Genetic testing has the potential to improve patient safety; however, its cost is high, and genetic polymorphisms account for only part of interindividual variation in dosing requirements. For obese patients, dose capping of low molecular weight heparin is not warranted, and twice-daily enoxaparin is preferred over once-daily dosing. Anti-Xa monitoring is perhaps not necessary for patients weighing less than 190 kg (418 lb), but it may be useful to adjust dosing in heavier patients. In patients with severe renal impairment, bleeding during anticoagulant therapy may be attributed to the uremic state, excessive doses, or both. Dosage reduction and anti-Xa monitoring are recommended for patients with severe renal impairment. Treatment of patients with HIT should include discontinuation of heparin, temporary interruption of warfarin therapy, and initiation of a direct thrombin inhibitor.. Safe and effective use of anticoagulant therapy may require consideration of genetics, obesity, renal impairment, or the potential for HIT; selecting anticoagulant therapy on the basis of these considerations can present a challenge.

Topics: Aged; Anticoagulants; Aryl Hydrocarbon Hydroxylases; Cytochrome P-450 CYP2C9; Female; Heparin; Humans; Kidney Diseases; Male; Middle Aged; Mixed Function Oxygenases; Obesity, Morbid; Pharmacogenetics; Polymorphism, Genetic; Thrombocytopenia; Vitamin K Epoxide Reductases; Warfarin

Perioperative management of bariatric surgical patients receiving chronic anticoagulation requires an understanding of potential hemorrhagic and thromboembolic risks. The aim of this study is to evaluate hemorrhagic and thromboembolic complications in morbidly obese patients who are on oral anticoagulation treatment and subsequently undergo laparoscopic bariatric surgery.. The medical records of all laparoscopic Roux-en-Y gastric bypass (LRYGB) patients from June 2001 to March 2006 were retrospectively reviewed. In addition, data of patients who received chronic anticoagulation therapy with Coumadin and underwent laparoscopic Roux-en-Y gastric bypass was analyzed. Clinical parameters included length of hospitalization, hemorrhagic complications, thromboembolic complications, conversion rate, reoperation, and blood transfusion.. During the study period, 1,700 consecutive patients underwent bariatric surgery for the treatment of morbid obesity. Of these, 21 patients were treated with chronic oral anticoagulation; 3 of the 21 (14%) had hemorrhagic complications: one patient had intraluminal hemorrhage and two patients had intraabdominal hemorrhage. Two patients required blood transfusion, and one patient underwent surgical reintervention. None of the 21 laparoscopic operations were converted to open procedures. There were no postoperative mortalities, and there were no thromboembolic events in this series.. Laparoscopic bariatric surgery can be performed relatively safely in morbidly obese patients who are treated with chronic oral anticoagulation. Even in the presence of bleeding, patients can be successfully treated without the need for reoperation.

Topics: Administration, Oral; Anticoagulants; Cardiovascular Diseases; Chronic Disease; Gastric Bypass; Hemorrhage; Humans; Laparoscopy; Obesity, Morbid; Retrospective Studies; Thromboembolism; Time Factors; Warfarin

Prolonged wound drainage following total hip or total knee arthroplasty has been associated with an increased risk of postoperative morbidity. The purpose of this study was to determine the pharmacologic, surgical, and patient-specific factors that are associated with prolonged wound drainage and the relationship of this complication to the length of hospital stay and the rate of wound infections.. We conducted a retrospective observational study of 1211 primary total hip arthroplasties and 1226 primary total knee arthroplasties. Prospectively collected data included body mass index, intraoperative blood loss, surgical time, type of prophylaxis against deep venous thrombosis, and length of hospital stay. The association of these factors with the duration of postoperative wound drainage was analyzed. An acute infection developed after fifteen primary total hip arthroplasties and ten primary total knee arthroplasties. The patients with an acute postoperative infection were compared with their uninfected counterparts, and an odds ratio was determined to estimate the risk of prolonged wound drainage resulting in a wound infection.. Morbid obesity was strongly associated with prolonged wound drainage in the total hip arthroplasty group (p = 0.001) but not in the total knee arthroplasty group (p = 0.590). An increased volume of drain output was an independent risk factor for prolonged wound drainage in both groups. Patients who received low-molecular-weight heparin for prophylaxis against deep venous thrombosis had a longer time until the postoperative wound was dry than did those treated with aspirin and mechanical foot compression or those who received Coumadin (warfarin); this difference was significant on the fifth postoperative day (p = 0.003) but not by the eighth postoperative day. Prolonged wound drainage resulted in a significantly longer hospital stay in both groups (p < 0.001). Each day of prolonged wound drainage increased the risk of wound infection by 42% following a total hip arthroplasty and by 29% following a total knee arthroplasty.. Morbid obesity, the use of low-molecular-weight heparin, and a higher drain output were associated with a prolonged time until the postoperative wound was dry following a primary total hip arthroplasty, whereas a higher drain output was the only risk factor associated with prolonged drainage following a primary total knee arthroplasty. Prolonged drainage was associated with a higher rate of infection following a primary total hip arthroplasty, whereas obesity was the only identified independent risk factor for postoperative infection following a primary total knee arthroplasty.

Topics: Aged; Arthroplasty, Replacement, Hip; Arthroplasty, Replacement, Knee; Aspirin; Body Mass Index; Drainage; Female; Heparin, Low-Molecular-Weight; Humans; Kaplan-Meier Estimate; Length of Stay; Linear Models; Logistic Models; Male; Middle Aged; Obesity, Morbid; Postoperative Complications; Retrospective Studies; Risk Factors; Surgical Wound Infection; Venous Thrombosis; Warfarin; Wound Healing

As the problem of morbid obesity has increased over the past several years in the United States, gastric bypass has become a viable option for many people seeking treatment. The risk of a venous thromboembolic event after gastric bypass is significant and linked to several factors. As the gastric bypass program at this southeastern hospital progressed, the number of thromboembolic complications increased. Because of the increase in postoperative thromboembolic events, a program was developed to improve outcomes and reduce the number of these events. The program currently uses a protocol that includes research-based preventive measures in conjunction with warfarin (Coumadin, Bristol Myers Squibb, Princeton, NJ) 1 mg daily for 30 days postoperatively with a target international normalized ratio of 1.8 or less. Before the initiation of the program, the event rate was 6.9%. The event rate for the evaluation period after initiation of the protocol was 1.3%. Further studies are needed to determine the full benefit of this type of program and whether the improvements gained were related to the use of warfarin (Coumadin).

Topics: Adult; Aged; Anticoagulants; Aspirin; Bandages; Clinical Protocols; Drug Monitoring; Early Ambulation; Evidence-Based Medicine; Female; Gastric Bypass; Heparin; Humans; International Normalized Ratio; Male; Middle Aged; Obesity, Morbid; Postoperative Care; Program Evaluation; Risk Factors; South Carolina; Thromboembolism; Vena Cava Filters; Venous Thrombosis; Warfarin

A 32-year-old, morbidly obese African-American woman developed bilateral pulmonary emboli 12 days after undergoing Roux-en-Y gastric bypass surgery. Three days later, after receiving heparin and warfarin, she developed heparin-induced thrombocytopenia type II (HIT-II). An argatroban 1.5-microg/kg/minute infusion was administered for approximately 2.5 days. The patient also received four doses of warfarin, totaling 37.5 mg. The argatroban infusion was discontinued early on hospital day 6, at which time the patient's international normalized ratio (INR) was 4.36 and activated partial thromboplastin time (aPTT) 85.9 seconds. Her INR and aPTT values continued to rise after the argatroban was discontinued and peaked 3 days later at 5.28 and 123.6 seconds, respectively. At this time her platelet count had improved from 139 x 10(3)/mm(3) to 543 x 10(3)/mm(3). No additional warfarin was administered before discharge. On hospital day 11, the patient was discharged home with an INR of 4.12 and an aPTT of 67.1 seconds. Her aPTT and INR values remained elevated for 19 days after receiving her last dose of warfarin and for 20 days after argatroban discontinuation. She experienced no bleeding complications from these supratherapeutic coagulation parameters. She resumed treatment with warfarin as an outpatient and completed a 6-month course of anticoagulation without further incident. Clinicians should be aware that coagulation parameters may remain elevated longer than expected after argatroban discontinuation in certain patients taking concomitant warfarin. Patients with liver dysfunction and obesity appear most likely to be affected.

Topics: Adult; Anticoagulants; Arginine; Drug Therapy, Combination; Female; Gastric Bypass; Heparin; Humans; International Normalized Ratio; Obesity, Morbid; Partial Thromboplastin Time; Pipecolic Acids; Pulmonary Embolism; Sulfonamides; Thrombocytopenia; Treatment Outcome; Warfarin

Pulmonary embolism is a leading cause of death for bariatric patients. Numerous regimens have been proposed, but a comprehensive, simple approach is lacking. This study provides a simple, easily implemented prophylaxis regimen.. One hundred fifty bariatric surgery patients were evaluated. Patients considered at high risk for venous thromboembolism had heart failure, a BMI of >/=50 kg/m(2), or a history of venous thromboembolism or pelvic surgery. Preoperatively and postoperatively, all patients received subcutaneous enoxaparin or unfractionated heparin. High-risk patients received either preoperatively inserted inferior vena cava filters or continuous heparin infusions intraoperatively. All high-risk patients were anticoagulated with warfarin (Coumadin; Bristol Myers-Squibb, Princeton, NJ) for at least 3 months postoperatively. Initially, some patients experienced significant hemorrhage; to prevent this, sutures were oversewn into staple lines.. No patient experienced venous thromboembolism; a binomial test showed that the regimen reduced the risk of this complication to less than 2% (p < 0.05). Hemorrhage sufficient to require transfusion occurred in 4 of the first 20 patients; of the remaining 130 patients, into whose staple lines sutures were oversewn, none required transfusion (p < 0.05).. Patients should be divided into those who are at high risk and those who are at low risk for venous thromboembolism. All patients should receive pre- and postoperative anticoagulation. High-risk patients should also receive either an inferior vena cava filter or intraoperative heparin infusions, as well as at least 3 months of Coumadin therapy. Oversewing of staple lines may reduce the risk of hemorrhage.

Topics: Anticoagulants; Bariatric Surgery; Body Mass Index; Enoxaparin; Hemorrhage; Heparin; Humans; Obesity, Morbid; Postoperative Complications; Retrospective Studies; Risk Factors; Thrombolytic Therapy; Treatment Outcome; Vena Cava Filters; Venous Thrombosis; Warfarin

A 43-year-old man presented 10 days after a Roux-en-Y gastric bypass with abdominal pain radiating to the back. Investigation revealed a thrombus in the superior mesenteric vein. The patient was found to have a hypercoagulable state. He responded successfully to anticoagulant therapy.

Topics: Adult; Anastomosis, Roux-en-Y; Anticoagulants; Gastric Bypass; Humans; Male; Mesenteric Vascular Occlusion; Mesenteric Veins; Obesity, Morbid; Radiography; Thrombophilia; Treatment Outcome; Venous Thrombosis; Warfarin