Warfarin Quality Metrics for Hospitalized Older Adults

Pharmacotherapeutic considerations for the management of cardiovascular diseases among hospitalized COVID-19 patients

INTRODUCTION

Cardiovascular diseases (CVDs) are among the most frequently identified comorbidities in hospitalized patients with COVID-19. Patients with CV comorbidities are typically prescribed with long-term medications. We reviewed the management of co-medications prescribed for CVDs among hospitalized COVID-19 patients.

AREAS COVERED

There is no specific contraindication or caution related to COVID-19 on the use of antihypertensives unless patients develop severe hypotension from septic shock where all antihypertensives should be discontinued or severe hyperkalemia in which continuation of renin-angiotensin system inhibitors is not desired. The continuation of antiplatelet or statin is not desired when severe thrombocytopenia or severe transminitis develop, respectively. Patients with atrial fibrillation receiving oral anticoagulants, particularly those who are critically ill, should be considered for substitution to parenteral anticoagulants.

EXPERT OPINION

An individualized approach to medication management among hospitalized COVID-19 patients with concurrent CVDs would seem prudent with attention paid to changes in clinical conditions and medications intended for COVID-19. The decision to modify prescribed long-term CV medications should be entailed by close follow-up to check if a revision on the decision is needed, with resumption of any long-term CV medication before discharge if it is discontinued during hospitalization for COVID-19, to ensure continuity of care.

Assessment of warfarin algorithms for hospitalized adults: searching for a safe dosing strategy

This study evaluates three warfarin dosing algorithms (Kimmel, Dawson, High Dose ≥ 2.5 mg) for hospitalized older adults. A random selection of 250 patients with overshoots (INR ≥ 5 after 48 h of hospitalization) and 250 patients without overshoots were accessed from a database of 12,107 inpatients ≥ 65 years treated with chronic warfarin during hospitalization between January 1, 2014 and June 30, 2016. Algorithms were retrospectively applied to patients 2 days prior to overshoots in the overshoot group, and 2 days prior to the maximum INR reached after 48 h of hospitalization in the non-overshoot group. Patients were categorized as overdosed or not overdosed and compared using descriptive statistics. Logistic regression modeling determined predictors for overshoots. There was no significant difference between overdose and non-overdose groups for progressing to overshoots by the Kimmel (51.0% vs. 48.7%, p = 0.67) or Dawson (48.5 vs. 57.9%, p = 0.19) algorithms. The Low Dose Group (≤ 2.5 mg) was significantly more likely to experience an overshoot than the High Dose Group (56.6% vs. 45.5%, p = 0.04). The Low Dose Group was more likely to be older (81.4% vs. 71.1%, p = 0.02), female (63.5% vs. 49.8%, p = 0.02), weigh less (71.3 ± 21.9 vs. 79 ± 23.1, p = 0.002), and be prescribed amiodarone (16.6% vs. 8.1%, p = 0.01). While none of the algorithms predicted overshoots in logistic regression modeling, weight over 70 kg and black race remained protective. The High Dose Algorithm revealed that providers appropriately gave lower doses to patients at highest risk for warfarin sensitivity. Future studies are needed to investigate tools for inpatient warfarin dosing in older adults.

Quality metrics of warfarin initiation in hospitalized older adults

Achieving therapeutic international normalized ratio (INRs) in warfarin naïve older adults can be complicated due to sensitivity factors. While multiple tools exist for warfarin initiation in the outpatient setting, there is a dearth of guidance for inpatient initiation. This study aims to: (1) describe a large health system's initiation warfarin quality metrics in older inpatients, defined by INR overshoots greater than or equal to 5.0; (2) identify intrinsic and extrinsic patient factors associated with overshoots; and (3) explore the association between inpatient overshoots and clinical outcomes. Data on inpatients ≥ 65 years initiated on warfarin 1/1/2014-6/30/2016 were extracted through retrospective chart review. The primary outcome was prevalence of overshoots (INR ≥ 5). Logistic regression modeling determined the risk factors for overshoots. Multivariate analysis was employed to associate overshoots with length of stay (LOS), bleeding, and mortality. Additional analysis of the impact of patient weight (kg) on overshoots was achieved through chi square analysis. Of 4556 inpatients initiated on warfarin, 8% experienced overshoots. Non-black race, peripheral vascular disease, chronic obstructive pulmonary disease (COPD), mild liver disease, low weight, and no statin use were found to be predictive of overshoots. Compared to the group without overshoots, the group with overshoots experienced a significantly increased LOS (13 days vs. 8 days, < 0.001), higher bleed rate (30.1% vs. 6.5%, adjusted OR 6.2, p < 0.001), and higher mortality rate (13.8% vs. 3.4%, adjusted OR 4.4, p < 0.001). Inpatient warfarin initiation was associated with frequent overshoots and poor outcomes. Future studies should focus on strategies to improve hospital warfarin initiation safety.