Adenosine remains the first-line pharmacologic agent for terminating atrioventricular node-dependent supraventricular tachycardia (SVT), but it is still administered as a fixed 6 mg bolus, escalating to 12 mg, regardless of body weight or body mass index (BMI). Because the same absolute dose is given across a wide range of body sizes, effective milligram-per-kilogram exposure falls as body weight rises, raising the question of whether fixed dosing still delivers equivalent therapeutic exposure in an increasingly heavier patient population. This review examines whether elevated BMI reduces the efficacy of standard adenosine dosing in SVT and evaluates the evidence for alternative dosing strategies.Multiple retrospective cohorts show that increased body weight and lower mg/kg exposure are independently associated with reduced first-dose cardioversion success. These patients who convert consistently received higher relative doses (approximately 0.09–0.10 mg/kg) than those who failed. Emerging evidence further suggests that obesity blunts the electrophysiologic response itself: obese patients exhibit significantly shorter post-adenosine sinus pauses than non-obese patients at standard doses. Two strategies have been proposed to close this exposure gap — individualized weight-based dosing, which is pharmacologically ideal but lacks prospective validation, and higher initial fixed-dose administration, which improves first-dose success (particularly among severely obese patients) while preserving the simplicity of current protocols.Collectively, the available evidence — though predominantly observational — supports reframing adenosine dosing around achieving adequate therapeutic exposure rather than delivering a predetermined absolute dose. Prospective pharmacokinetic studies and randomized trials comparing dosing strategies are needed before guideline changes can be confidently recommended.