In extremely obese patients with spontaneous DVT/PE who have been anticoagulated for > 6 months, do you feel comfortable reducing the DOAC to prophylactic dose or do you prefer continuing full dose indefinite anticoagulation?

According to the ISTH guidelines (Martin et al., PMID 34259389) in patients with a BMI >40 kg/m² or weighing >120 kg, it is suggested to use the standard doses of apixaban or rivaroxaban for VTE treatment and prevention regardless of BMI and BW. The ISTH did not discuss dose reduction after 6 months...

In extremely obese patients with unprovoked VTE, I prefer to continue full dose anticoagulation if they are tolerating it without any side effects, especially if they had an extensive VTE and have other cardiovascular risk factors.

If there is any concern for bleeding risk or if the patient does not...

Agree with what has been said before. I only dose reduce if there is an increase in menstrual bleeding, especially if that leads to anemia.