2021 ISTH SCC Guidance¹

• For patients with a BMI >40 kg/m² or weight >120 kg, individual DOACs are recommended to be used as follows:
• VTE treatment: Suggest that standard doses of rivaroxaban or apixaban are among appropriate anticoagulant options regardless of high BMI and body weight; fewer supportive data exist for apixaban than rivaroxaban
• Primary prevention of VTE: Suggest that standard doses of rivaroxaban or apixaban are among appropriate anticoagulant options, regardless of high BMI and weight
• Suggest not to use dabigatran, edoxaban, or betrixaban for VTE treatment and prevention for patients with BMI >40 kg/m² or body weight >120 kg, given unconvincing data for dabigatran and lack of clinical or PK/PD data for edoxaban and betrixaban
• Suggest not to regularly follow peak or trough drug-specific DOAC levels, because there are insufficient data to influence management decisions
• Suggest not to use DOAC for the treatment or prevention of VTE in the acute setting after bariatric surgery; instead, suggest initiating such patients on parenteral anticoagulation in the early postsurgical phase
• Suggest that switching to VKA or DOAC may be considered after ≥4 weeks of parenteral treatment, and if so, suggest obtaining a DOAC trough level to check for drug absorption and bioavailability