Use of Eliquis and Xarelto After Gastric Banding or Other Weight Loss Surgery

Dr. Stephan Moll writes (last updated: March 25^th, 2020)…

Question: Can a person who needs to be on a blood thinner and who has had gastric banding or gastric bypass surgery for weight loss be on Eliquis®, Xarelto®, Pradaxa®, or Savaysa®?

Answer: Warfarin is currently the preferred choice, because the absorption of the direct oral anticoagulants (DOACs) – i.e. Eliquis®, Xarelto®, Pradaxa®, or Savaysa® – after such bariatric procedures is potentially impaired [ref 1,2].

Background: All blood thinners (anticoagulants) are absorbed in the first part of the intestine (distal stomach, duodenum or proximal jejunum). After any type of gastric bypass weight loss procedure/surgery – gastric banding, Roux-en-Y gastric bypass, sleeve gastrectomy, etc. -, the absorption of these drugs may be impaired [ref 1]. The concern is that the blood level of the blood thinner may, therefore, be too low, and, thus, ineffective in preventing recurrent clots. Clinical data on the degree of absorption, blood levels of the DOACs achieved, and clinical success or failure rates are limited [ref 1,2].  Peer-reviewed publications, therefore, suggest avoidance of DOACs after bariatric procedures:

• “We avoid the use of DOACs in patients after bariatric surgery and await further clinical trials” [ref 2]
• “We prefer to use warfarin as a first line anticoagulant in patients who have had bariatric surgery” [ref 1]

My Own Practice: I prefer to use warfarin (Coumadin®) in patients who have had a gastric weight loss procedure/surgery. However, in the occasional patient who had gastric banding or weight loss surgery months or years ago, a DOAC seems reasonable:

• In the patient referred to my clinic who is already on a DOAC, I obtain a DOAC blood level (trough, just before the next DOAC dose is due) to determine whether he/she is in the expected range. If he/she is, then it seems reasonable to continue the DOAC. The reference ranges of “expected trough blood levels” I use are the data in Table 1 from reference #3.
• In the patient in whom warfarin is a significant problem, using a DOAC seems reasonable, with testing of a DOAC trough drug level.

References

1. Moll S, Martin KA. Anticoagulant drug choice in patients who have had bariatric surgery – Presently, DOACs are not the preferred choice.  Thromb Res. 2018 Mar;163:196-199.
2. Wang TF, Carrier M. How I treat obese patients with oral anticoagulants. Blood. 2020 Mar 19;135(12):904-911.
3. Samuelson BT et al. Laboratory Assessment of the Anticoagulant Activity of Direct Oral Anticoagulants. A Systematic Review. Chest 2017; 151(1):127-138.

Disclosure: I have consulted for Bristol Myers Squibb.