Anticoagulation in obese patients: challenges and strategies

Obesity is a chronic complex disease, related to several comorbidities, including cardiovascular diseases, insulin resistance, and venous thromboembolism (VTE). Its rising prevalence, especially among individuals with extreme obesity, poses several management challenges, particularly with regard to anticoagulant therapy. The pharmacokinetics and pharmacodynamics of anticoagulants are altered in obese patients, requiring tailored therapeutic strategies. This review examines the challenges faced when managing anticoagulation in obese individuals, focusing on both parenteral and oral anticoagulants. Obesity influences drug absorption, distribution, metabolism, and elimination, complicating the use of both parenteral agents like low-molecular-weight heparin (LMWH), unfractionated heparin (UFH), and fondaparinux and oral agents, such as vitamin K antagonists (VKAs) and direct oral anticoagulants (DOACs). Oral anticoagulant administration represents a great challenge also in patients who undergo bariatric surgery, which further impacts on drug bioavailability by modifying gastrointestinal anatomy. In general, data on the efficacy and safety of DOACs in severely obese individuals, particularly those who have undergone bariatric surgery, remain limited. This review highlights the importance of individualized anticoagulation approaches, especially for high-risk patients, and highlights the need for further research to establish appropriate management strategies for the population of obese patients. Such studies are crucial to improve the safety and efficacy of anticoagulant therapy in this growing population.