Oral anticoagulant treatment in children based on monitoring at home

A regional anticoagulation program improves safety and outcomes for both children and adults

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.

Self-testing and self-management of oral anticoagulation therapy in children

Children and adolescents on oral anticoagulation therapy (OAT) present special challenges in terms of rapid fluctuations in International Normalised Ratio (INR) values, interruption in daily life due to frequent hospital/doctor visits, and difficulties and pain in the performance of venepuncture. Optimised management of OAT improves the quality of treatment, potentially accomplished by new methods such as patient self-testing (PST) and patient self-management (PSM). A review was performed, identifying 11 trials with children and adolescents. All studies had different methodological problems, predominantly by being non-randomised trials. A total of 284 patients were included with a mean follow-up of 22 months, finding a time within therapeutic INR target range between 63% and 84%. The coagulometers used for estimating the INR values were found to have sufficient precision and accuracy for clinical use, but external quality control is probably advisable. It can be concluded that PST and PSM are at least as good treatment options as conventional management in highly selected children. Larger studies, preferably randomised, controlled trials using clinical endpoints, are obviously needed in order to elucidate whether these new regimens of treatment are superior to conventional management of oral anticoagulation therapy.

Safety and Efficacy Outcomes of Home and Hospital Warfarin Management Within a Pediatric Anticoagulation Clinic

The complexity of managing children with chronic disease has led to an increase in the use of long-term warfarin therapy. Time in therapeutic range (TTR) is the preferred method for determining efficacy and stability of warfarin management. This study aimed to determine the TTR achievement and incidence of adverse events among pediatric warfarin patients managed by an anticoagulation clinic over 12 months and to compare TTR achievement between patients self-testing (PST) at home and those monitored using routine methods. International normalized ratio (INR) results reported for 2012 for children currently having their warfarin therapy managed by a dedicated pediatric anticoagulation clinic were analyzed. Warfarin-related adverse events were recorded. A total of 164 patients were included. In total, 93 children performed PST and 71 children tested their INR at a hospital or pathology service. TTR achievement for the cohort was 67.1% (95% confidence interval, 64.4-69.7). A total of 69.2% of INR tests conducted at home were within the TTR compared with 64.3% of INR tests conducted at a hospital or pathology service (P=0.07). One major bleeding event occurred and there was 1 thrombotic episode. PST demonstrated noninferior warfarin stability compared with routine methods. Routine outcome evaluation of pediatric anticoagulation management within single institutions is necessary to confirm the success of such programs.

EMPoWARed: Edmonton pediatric warfarin self-management study

BACKGROUND

Patient self-management (PSM) in adults is safer and more cost effective than conventional management. Warfarin is a narrow therapeutic index drug with individual patient response to changes and frequently a long-term therapy. Children and their families are proposed to be able to effectively manage their child's warfarin therapy. Increased health related quality of life is highly associated with effective therapy in patients with chronic conditions.

OBJECTIVES

The aim of this study is to evaluate the safety and efficacy of PSM over time including HRQOL and variables that may influence PFU success at PSM.

PATIENTS/METHODS

Children and their family units (PFUs) current performing patient self-testing/monitoring for ≥ 3 months were enrolled in this cohort study. PFUs participated in comprehensive education on warfarin testing and management followed by an apprenticeship. Socio-demographic, clinical, and laboratory data were collected to evaluate safety and efficacy and health related quality of life. Outcomes were compared between the first 6 months on PSM (phase 1) and the last 6 months data collected on PSM (phase 2).

RESULTS

Forty-two patients performed PSM for a median of 2.7 years (range: 1.1-6.2 years). Time in therapeutic range was 90% and 92.9% (p=0.30) in phases 1 and 2 respectively. All measures were strongly associated with improved heath related quality of life. PFUs socio-demographic status did not influence success at PSM. All PFUs maintained warfarin knowledge and INR testing competency. Warfarin dosing decision errors median 0 (range: 0-5, p=0.73) and a median 0 (range 0-4, p=0.55) per patient in phases 1 and 2 respectively. There were no adverse hemorrhagic or thrombotic events.

CONCLUSIONS

Empowering PFUs to self-manage warfarin results in increased knowledge and understanding of their health condition, improved commitment to their health care and adherence to medication regimens and is demonstrated to be sustainable over time.

Quality of life assessment in children commencing home INR self-testing

INTRODUCTION

Management of oral anticoagulant therapy (OAT) in children is complex and frequent testing of the International Normalised Ratio (INR) is a significant burden. This study evaluates the impact of a home INR self-testing (home ST) program on the quality of life (QoL) of children and their families. The aim of the study was to determine if participation in a home ST program improves QoL for children requiring long-term OAT and their families.

MATERIALS AND METHODS

Children aged eight to 18 years requiring long-term OAT and parents of children participated. Quantitative methods comprised three validated QoL questionnaires; the anticoagulation specific PAC QL©, the PedsQL™ and the PedsQL FIM™. Questionnaires were completed before commencing home ST and 6-12 months later. Qualitative methods consisted of open-ended questions which participants answered when completing the questionnaires for the second time. Results of INRs tested at home were collected.

RESULTS

Fifty-five parents and 35 children participated. The percentage of time the children's INRs were in their target therapeutic range was 71.3. Parents reported statistically significant improvements in QoL for themselves (mean increase 6.9), their family (mean increase 8.6) and their child (mean increase 11.1) following the commencement of home ST (difference p≤0.003 on all questionnaires). The children did not report a statically significant improvement in QoL.

CONCLUSION

Parents reported significant improvement for their child's QoL, their QoL and the families' function following commencement of home ST. Children did not report a significant improvement in their QoL, but clearly identified satisfaction with home ST.

Evaluating safety, effectiveness, and user satisfaction of home international normalized ratio monitoring service: experience from a tertiary pediatric cardiology unit in the United Kingdom

Home international normalized ratio (INR) monitors are being increasingly used for monitoring the adequacy of anticoagulation in children on long-term warfarin. Their safety and effectiveness in the home setting has not been fully established. The purpose of this study was to explore the safety and effectiveness of home INR monitoring service in managing anticoagulation in children with congenital heart disease. At the Pediatric Cardiology Regional Referral Center, we studied records of 41 children on warfarin and assessed the control of anticoagulation and frequency of adverse reactions over a 1-year period. User satisfaction was assessed by means of telephone interviews. The study found that the therapeutic INR range was maintained for over 57% of the total study period. There were no reported instances of major or minor hemorrhages. On six occasions, subtherapeutic INR levels necessitated hospitalization for heparinization. Mitral valve replacement was significantly associated with poor control (p < 0.05). User satisfaction was high for all aspects of the service evaluated. The hospital-assisted home INR monitoring service is a safe and effective means of managing anticoagulation in children. In addition, it ensures good compliance and a high level of user satisfaction.

KIDCLOT: the importance of validated educational intervention for optimal long term warfarin management in children

BACKGROUND

Advances in medical and surgical therapy in children have resulted in increased survival in children with primary illnesses. However, thrombosis is a serious complication of this success and results in mortality and morbidity. Prevention or treatment of thrombosis using warfarin is challenging in children due to its narrow therapeutic index and the unique differences in children, including variable nutritional intake and the occurrence of common concomitant viral or bacterial illnesses which alter warfarin metabolism. The variable response to warfarin in children necessitates frequent International Normalized Ratio (INR) monitoring. Education may improve time in therapeutic range (TTR) a measure of warfarin effect, and a surrogate for patient adherence, safety and efficacy.

METHODS

The Pediatric Anticoagulation program (Stollery Children's Hospital) developed a novel child-focused educational program KIDCLOT-POC about warfarin therapy and POC-INR meter use. A total of twenty eight children, and their caregivers, participated in KIDCLOT-POC. Questionnaire score comparisons and practical demonstrations assessed the learners' theoretical and practical knowledge of warfarin management.

RESULTS

In caregivers, the median pre, post and knowledge retention questionnaire scores were 50 (IQR 27), 93 (IQR 6) (p<0.0001) and 96 (IQR 6) (p<0.0001), respectively. In the 18 children who were >or=6 years of age, post and knowledge retention questionnaire scores were 90 (IQR 16) and 92 (IQR 23) (p=0.44), respectively. The TTR for all children was 81.7% (SD 13.1).

CONCLUSIONS

Implementation of KIDCLOT-POC program appears to promote high knowledge development and retention in children and caregivers and high TTR with no adverse events.

Validity of CoaguChek S for home monitoring of anticoagulant therapy in pediatrics

BACKGROUND

CoaguChek S (Roche Diagnostics, Canada) is a portable device designed to monitor international normalized ratio (INR) by capillary puncture. Although the device is used in pediatrics, no study has evaluated its validity in patients of this population.

OBJECTIVE

To evaluate the validity of CoaguChek S as an in-home INR monitor in patients younger than 18 years of age.

METHODS

Data were based on 129 INR pairs collected from nine patients younger than 18 years of age followed up at an anticoagulation clinic between March 1, 2000, and January 19, 2004. The INRs from both the laboratory and CoaguChek S were used to evaluate concordance between the two methods using the intraclass correlation coefficient.

RESULTS

The overall intraclass correlation coefficient between the CoaguChek S and the laboratory was 0.75 (95% CI 0.66 to 0.82). On average, CoaguChek S underestimated INRs by 0.11+/-0.54 units compared with those of the laboratory. INRs of 3.5 units and higher obtained with CoaguChek S were, on average, 0.49+/-1.09 units higher than those obtained in the laboratory.

CONCLUSIONS

CoaguChek S appears to be a valid instrument for in-home INR monitoring for most patients younger than 18 years of age, with INR targets of 2.0 to 3.0 followed up by an anticoagulant therapy clinic's program. However, caution must be used when interpreting INRs higher than 3.5. Parents should perform a second test to confirm all CoaguChek S INR results higher than 4.0.