Table 7 High-risk obese patient subgroups that may require variations of VTE treatment

Do considerations for treatment of obese patients at high risk of VTE vary between patient subgroups?

• Subgroups in obese patients are poorly studied

• Treatments vary between different patient weight groups: obese, morbidly obese

• The subgroup of obese patients > 120 kg is problematic

• Different weight groups require different anticoagulant treatments

• Standardised treatment regimens with enoxaparin exist in some hospitals

• Medical and surgical obese patients need to be considered as two separate groups

• Bariatric surgery or non-bariatric surgery patients and medical patients should be considered separately

• Surgical obese patients should be differentiated into those undergoing bariatric surgery or any other surgery

• There are differences in how these patients are defined as high risk

ACCP [28]:

• Graduated compression stockings are recommended for severely obese patients considering long distance travel

ISTH [76]:

• Standard dosing of DOACs is recommended for obese patients with a weight < 120 kg

• DOACs should not be used in obese patients with a weight > 120 kg but if they are then drug-specific peak and trough levels should be checked

NICE [38]:

• Further research is needed regarding dose strategies of LMWH for very obese people (BMI > 35) who are admitted to hospital or receiving day procedures

• Mechanical prophylaxis is recommended for patients undergoing bariatric surgery

RCOG [13]:

• Risk of VTE during pregnancy increases with a BMI > 25 and ante-partum immobilisation

SOGC [30]:

• Recommended dose increases for UFH, enoxaparin, dalteparin and tinzaparin are indicated for obese pregnant women

Thrombosis Canada [78]:

• Obese patients between 40–100 kg are recommended higher doses of dalteparin, enoxaparin and tinzaparin than patients < 40 kg to be taken once daily. This dose is increased to twice daily for those weighing 101–120 kg