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Rodriguez V, Stanek J, Cua CL, Sankar A, Giver J, Monda K, Canini J, Dunn AL, Kerlin BA. A regional anticoagulation program improves safety and outcomes for both children and adults. J Thromb Thrombolysis 2023:10.1007/s11239-023-02806-w. [PMID: 37093351 DOI: 10.1007/s11239-023-02806-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/01/2023] [Indexed: 04/25/2023]
Abstract
BACKGROUND Evidence-based anticoagulation programs usually serve a local, adult patient population. Here we report outcomes for a regional combined pediatric-adult program. AIMS The aims of this study were: (1) Compare the pre- vs. post-implementation quality of therapy (% time in therapeutic range (%TTR) and compliance). (2) Assess anticoagulant-relevant outcomes (bleeding and thrombotic complications). METHODS Data were collected for the years 2014-2019. Rosendaal linear interpolation was used to calculate %TTR. Bleeding complications were categorized using ISTH-SSC standard nomenclature and new thrombotic events were reviewed. RESULTS The patients were divided into a long-term warfarin group (N = 308), 80.2% of whom had cardiac-related therapeutic indications (median age 24y), and a second group (N = 114) comprised of short-term and non-warfarin long-term anticoagulation (median age 16y). Median %TTR for those on long-term warfarin was 78.9%. The incidence of major and clinically relevant non-major bleeding events was 1.65 and 2.43 /100 person-years of warfarin use, respectively. Thromboembolism (TE) incidence was 0.78/100 patient-years of warfarin use. Neither bleeding nor thrombosis was associated with %TTR (p = 0.48). Anticoagulant indication was the only variable associated with bleeding risk (p = 0.005). The second group had no on-therapy TE events but 7.9% experienced bleeding. Complete data were available for a randomly sampled pre-program warfarin group (N = 26). Median %TTR improved from 17.5 to 87% pre- vs. post-implementation. Similarly, compliance (defined as ≥ 1 INR/month) improved by 34.3%. CONCLUSIONS In conclusion, this program significantly improved and sustained %TTR and compliance. The lack of association between bleeding and thrombosis events and %TTR may be related to the high median %TTR (> 70%) achieved by this approach.
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Affiliation(s)
- Vilmarie Rodriguez
- Division of Hematology/Oncology/BMT, Nationwide Children's Hospital, The Ohio State University, 700 Children's Drive, Columbus, OH, 43205, USA.
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA.
| | - Joseph Stanek
- Division of Hematology/Oncology/BMT, Nationwide Children's Hospital, The Ohio State University, 700 Children's Drive, Columbus, OH, 43205, USA
- Biostatistics Resource at Nationwide Children's Hospital, Columbus, OH, USA
| | - Clifford L Cua
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Amanda Sankar
- Division of Hematology/Oncology/BMT, Nationwide Children's Hospital, The Ohio State University, 700 Children's Drive, Columbus, OH, 43205, USA
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
- Division of Cardiology, Nationwide Children's Hospital, Columbus, OH, USA
| | - Jean Giver
- Division of Hematology/Oncology/BMT, Nationwide Children's Hospital, The Ohio State University, 700 Children's Drive, Columbus, OH, 43205, USA
| | - Kay Monda
- Division of Hematology/Oncology/BMT, Nationwide Children's Hospital, The Ohio State University, 700 Children's Drive, Columbus, OH, 43205, USA
| | - Joan Canini
- Division of Hematology/Oncology/BMT, Nationwide Children's Hospital, The Ohio State University, 700 Children's Drive, Columbus, OH, 43205, USA
| | - Amy L Dunn
- Division of Hematology/Oncology/BMT, Nationwide Children's Hospital, The Ohio State University, 700 Children's Drive, Columbus, OH, 43205, USA
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Bryce A Kerlin
- Division of Hematology/Oncology/BMT, Nationwide Children's Hospital, The Ohio State University, 700 Children's Drive, Columbus, OH, 43205, USA
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
- Center for Clinical and Translational Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH, USA
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Ting C, Sylvester KW, Schurr JW. Time in the Therapeutic Range for Assessing Anticoagulation Quality in Patients Receiving Continuous Unfractionated Heparin. Clin Appl Thromb Hemost 2018; 24:178S-181S. [PMID: 30213200 PMCID: PMC6714859 DOI: 10.1177/1076029618798944] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Due to variable pharmacokinetic properties, therapeutic anticoagulation with continuous
unfractionated heparin (UFH) requires ongoing laboratory monitoring, generally with
activated partial thromboplastin time (aPTT). In the ambulatory setting, clinicians who
manage warfarin therapy often use time in the therapeutic range (TTR) to estimate a
percentage of time the international normalized ratio is therapeutic. We applied the TTR
concept to aPTT monitoring for therapeutic UFH and used 2 methodologies for estimation:
percentage of aPTT values in range (%aIR) and a modification of the Rosendaal method
(mod-Rosendaal). This study included adult inpatients admitted between September 30, 2015,
and September 30, 2016, at Brigham and Women’s Hospital. For each patient, all available
aPTT values were extracted to calculate 2 individual TTRs according to each methodology.
Comparison between methods was performed using Student t test, and
correlation was assessed with simple linear regression. A total of 255 patients were
included in this study. The major outcome of TTR estimation was significantly higher using
mod-Rosendaal (43.7% [26.5%]) versus %aIR (37.7% [25.7%], P = .012) by a
mean difference of 6% points (95% confidence interval: 1.3-10.7). Time in the therapeutic
range estimated by mod-Rosendaal significantly correlated with those estimated by %aIR
(r = 0.84, P < .001). Further studies should
evaluate the correlation between TTR and clinical outcomes and establish a benchmark for
quality therapeutic anticoagulation with continuous UFH.
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Affiliation(s)
- Clara Ting
- Department of Pharmacy, Brigham and Women's Hospital, Boston, MA, USA
| | | | - James W Schurr
- School of Medicine, Stony Brook University, Stony Brook, NY, USA
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Maagdenberg H, Bierings MB, van Ommen CH, van der Meer FJM, Appel IM, Tamminga RYJ, de Boer A, Maitland-van der Zee AH. Characteristics and quality of oral anticoagulation treatment in pediatric patients in the Netherlands based on the CAPS cohort. J Thromb Haemost 2018; 16:116-124. [PMID: 29108090 DOI: 10.1111/jth.13897] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Indexed: 01/31/2023]
Abstract
Essentials The knowledge of quality and safety of acenocoumarol and phenprocoumon use in children is limited. We used data from a multicenter retrospective follow-up study in children in the Netherlands. The quality of anticoagulation control in the first month of use was low, but improved thereafter. No thromboembolic events occurred, however bleeding events occurred in 1-3 out of 10 patients. SUMMARY Background The use of vitamin-K antagonists in pediatric patients is rare and information on the quality and safety of treatment with acenocoumarol and phenprocoumon is limited. Objectives To assess the quality, safety and effectiveness during the first year of acenocoumarol and phenprocoumon treatment in pediatric patients in the Netherlands. Methods The Children Anticoagulation and Pharmacogenetics Study (CAPS) was designed as a multicenter retrospective follow-up study. Patients who used acenocoumarol or phenprocoumon at an age of ≤ 18 years, were selected from four pediatric hospitals and one anticoagulation clinic in the Netherlands. The quality of treatment was assessed by calculating the percentage of time in therapeutic INR range (TTR) for the first month and for every 3 months of use during the first year of treatment. Effectiveness and safety were assessed by the number of thromboembolic and bleeding events. Results In total, 213 patients participated, of whom 187 (155 acenocoumarol; 32 phenprocoumon) were included in this analysis. The mean TTR was 47.0% and 51.4% in the first month of use for acenocoumarol and phenprocoumon, respectively. After the first 3 months the mean TTR for both VKAs was above 64%. In 14.6% (acenocoumarol) and 31.3% (phenprocoumon) of the patients a bleeding event occurred during the first year of treatment; no thromboembolic events were reported. Conclusions The quality of anticoagulation treatment was low during the first month of use and leaves room for improvement. After the first month it increased to an acceptable level. However, bleeding events occurred frequently during the first year.
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Affiliation(s)
- H Maagdenberg
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Faculty of Science, Utrecht University, Utrecht, the Netherlands
| | - M B Bierings
- Department of Pediatric Hematology and Stem Cell Transplantation, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, the Netherlands
| | - C H van Ommen
- Department of Pediatric Oncology/Hematology, Erasmus MC/Sophia Children's Hospital, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - F J M van der Meer
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - I M Appel
- Department of Pediatric Oncology/Hematology, Erasmus MC/Sophia Children's Hospital, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - R Y J Tamminga
- Department of Pediatric Hematology, University Medical Center Groningen, Groningen, the Netherlands
| | - A de Boer
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Faculty of Science, Utrecht University, Utrecht, the Netherlands
| | - A H Maitland-van der Zee
- Department of Respiratory Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
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Nagler M, Bachmann LM, Schmid P, Raddatz Müller P, Wuillemin WA. Patient self-management of oral anticoagulation with vitamin K antagonists in everyday practice: efficacy and safety in a nationwide long-term prospective cohort study. PLoS One 2014; 9:e95761. [PMID: 24748062 PMCID: PMC3991723 DOI: 10.1371/journal.pone.0095761] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Accepted: 03/30/2014] [Indexed: 12/20/2022] Open
Abstract
Patient self-management (PSM) of oral anticoagulation is under discussion, because evidence from real-life settings is missing. Using data from a nationwide, prospective cohort study in Switzerland, we assessed overall long-term efficacy and safety of PSM and examined subgroups. Data of 1140 patients (5818.9 patient-years) were analysed and no patient were lost to follow-up. Median follow-up was 4.3 years (range 0.2-12.8 years). Median age at the time of training was 54.2 years (range 18.2-85.2) and 34.6% were women. All-cause mortality was 1.4 per 100 patient-years (95% CI 1.1-1.7) with a higher rate in patients with atrial fibrillation (2.5; 1.6-3.7; p<0.001), patients>50 years of age (2.0; 1.6-2.6; p<0.001), and men (1.6; 1.2-2.1; p = 0.036). The rate of thromboembolic events was 0.4 (0.2-0.6) and independent from indications, sex and age. Major bleeding were observed in 1.1 (0.9-1.5) per 100 patient-years. Efficacy was comparable to standard care and new oral anticoagulants in a network meta-analysis. PSM of properly trained patients is effective and safe in a long-term real-life setting and robust across clinical subgroups. Adoption in various clinical settings, including those with limited access to medical care or rural areas is warranted.
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Affiliation(s)
- Michael Nagler
- Division of Haematology and Central Haematology Laboratory, Luzerner Kantonsspital, Lucerne, and Department of Haematology and Central Haematology Laboratory, Inselspital University Hospital, Berne, Switzerland
| | | | - Pirmin Schmid
- Division of Haematology and Central Haematology Laboratory, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Pascale Raddatz Müller
- Division of Haematology and Central Haematology Laboratory, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Walter A. Wuillemin
- Division of Haematology and Central Haematology Laboratory, Luzerner Kantonsspital, 6000 Lucerne, and University of Berne, Berne, Switzerland
- * E-mail:
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Lowry AW, Moffett BS, Moodie D, Knudson JD. Warfarin anticoagulation after congenital heart surgery at a large children's hospital. Pediatr Cardiol 2012; 33:1377-82. [PMID: 22588460 DOI: 10.1007/s00246-012-0351-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2012] [Accepted: 04/27/2012] [Indexed: 12/01/2022]
Abstract
Management of warfarin in pediatric patients remains a clinical challenge. Warfarin may be administered after congenital heart surgery, and the risks of morbidity can be high. Currently, no data exist to describe the initiation of warfarin and the risk factors for morbidity in post-congenital heart surgery patients. This study aimed to characterize the time required to reach anticoagulation for patients administered warfarin therapy after cardiac surgery and to identify and characterize the risk factors for supratherapeutic anticoagulation and adverse events after warfarin initiation. This retrospective study reviewed all patients between 2006 and 2011 who received warfarin anticoagulation after cardiac surgery at our institution. Factors associated with a prolonged time required to reach an international normalized ratio (INR) of 2 and factors related to supratherapeutic anticoagulation (INR ≥ 4) were identified. The inclusion criteria were met by 59 patients. The median time required to reach an INR of at least 2 after initiation of warfarin was 2 days (interquartile range (IQR), 2-4). The only groups that required a significantly longer time to reach an INR of 2 were those with a postoperative delay in initiation of warfarin and those receiving heparin anticoagulation before and during warfarin initiation. Nine patients experienced an INR of 4 or more. However, no thrombotic events occurred, and significant bleeding was uncommon. In the largest reported group of patients undergoing anticoagulation after cardiac surgery, warfarin was well tolerated across all age groups. The median time required to reach an INR of 2 after loading with warfarin was 2 days, and adverse events were uncommon.
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Affiliation(s)
- Adam W Lowry
- Department of Pediatrics, Lillie Frank Abercrombie Section of Pediatric Cardiology, Baylor College of Medicine, Houston, TX, 77030, USA
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