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Van Beek A, Moeyaert M, Ragheb B, Price E, MacEwan JP, Ahmed N, Ansell J. Outcomes of Warfarin Home INR Monitoring vs Office-Based Monitoring: a Retrospective Claims-Based Analysis. J Gen Intern Med 2024; 39:1127-1134. [PMID: 38100006 PMCID: PMC11116318 DOI: 10.1007/s11606-023-08348-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 07/03/2023] [Accepted: 07/21/2023] [Indexed: 05/25/2024]
Abstract
BACKGROUND Home INR testing (patient self-testing) is feasible and effective for warfarin patients but little is known about real-world differences in outcomes for patients using PST versus laboratory-based INR monitoring. OBJECTIVE To compare the safety/efficacy of patient self-testing of real-world warfarin therapy versus office/lab-based monitoring of therapy. DESIGN/SETTING/PARTICIPANTS/EXPOSURE A retrospective claims-based analysis of warfarin patients enrolled in the MarketScan® Commercial Claims and Encounters and Medicare databases between January 1, 2013, and March 30, 2020. Stratification was based on INR testing method: patient self-testing versus testing at physicians' offices/local laboratory. The probability of adverse events in each cohort was determined after adjusting for demographic and baseline clinical characteristics using a repeated measures analysis. MAIN MEASURES Rates of all adverse events: deep venous thrombosis, pulmonary embolism, bleeding, and stroke. A secondary outcome of interest was emergency department visits. KEY RESULTS A total of 37,837 patients were included in the analysis: 1592 patients in the patient self-testing group and 36,245 in the office-based therapy group. After adjusting for demographic and baseline clinical characteristics, patients in the office-based group had statistically significantly higher rates of all adverse events (incidence rate ratio [IRR]=2.07, 95% CI [1.82, 2.36]), and specific adverse events including thromboembolism (IRR=4.38, 95% CI [3.29, 5.84]), major bleed (IRR=1.45, 95% CI [1.28, 1.64]), and stroke (IRR=1.30, 95% CI [1.05, 1.61]) than patients in the patient self-testing group. Office-based patients also had a statistically significant higher rate of emergency department visits than patient self-testing patients (IRR = 1.65, 95% CI [1.47, 1.84]). CONCLUSIONS/RELEVANCE This analysis of real-world claims data shows lower rates of stroke, thromboembolism, and major bleeding, as well as fewer emergency department visits, with patient self-testing compared to office-based/lab INR monitoring. Our finding that PST is safe and effective among current users suggests that more patients may benefit from its use.
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Affiliation(s)
| | - Mariola Moeyaert
- University at Albany - State University of New York, Albany, NY, USA
| | - Bishoy Ragheb
- VA Eastern Colorado Health Care System, Aurora, CO, USA
| | - Erika Price
- San Francisco VA Health Care System, University of California San Francisco, San Francisco, CA, USA
| | | | | | - Jack Ansell
- Hofstra Northwell Zucker School of Medicine, Hempstead, NY, USA.
- , Long Branch, NJ, USA.
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O'Neil MJ, Garr BN, Faircloth JM, Ciambarella JA, Lubert AM, Nelson NL, Cooper DS. Utility of a pharmacist-managed Anticoagulation Program in patients with congenital heart disease. Cardiol Young 2024; 34:628-633. [PMID: 37681464 DOI: 10.1017/s1047951123003268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Abstract
BACKGROUND Warfarin remains the preferred anticoagulant for many patients with CHD. The complexity of management led our centre to shift from a nurse-physician-managed model with many providers to a pharmacist-managed model with a centralized anticoagulation team. We aim to describe the patient cohort managed by our Anticoagulation Program and evaluate the impact of implementation of this consistent, pharmacist-managed model on time in therapeutic range, an evidence-based marker for clinical outcomes. METHODS A single-centre retrospective cohort study was conducted to evaluate the impact of the transition to a pharmacist-managed model to improve anticoagulation management at a tertiary pediatric heart centre. The percent time in therapeutic range for a cohort managed by both models was compared using a paired t-test. Patient characteristics and time in therapeutic range of the program were also described. RESULTS After implementing the pharmacist-managed model, the time in therapeutic range for a cohort of 58 patients increased from 65.7 to 80.2% (p < .001), and our Anticoagulation Program consistently maintained this improvement from 2013 to 2022. The cohort of patients managed by the Anticoagulation Program in 2022 included 119 patients with a median age of 24 years (range 19 months-69 years) with the most common indication for warfarin being mechanical valve replacement (n = 81, 68%). CONCLUSIONS Through a practice change incorporating a collaborative, centralized, pharmacist-managed model, this cohort of CHD patients on warfarin had a fifteen percent increase in time in therapeutic range, which was sustained for nine years.
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Affiliation(s)
- Meredith J O'Neil
- Division of Pharmacy, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - BreAnn N Garr
- Division of Pharmacy, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | | | - Julie A Ciambarella
- Department of Pediatrics, The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Adam M Lubert
- Department of Pediatrics, The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Nicole L Nelson
- Department of Pediatrics, The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - David S Cooper
- Department of Pediatrics, The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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Bauman M, Hellinger A, Pluym CV, Bhat R, Simpson E, Mehegan M, Knox P, Massicotte M. Online KidClot education for patients and families initiating warfarin therapy: The eKITE study. Thromb Res 2022; 215:14-18. [PMID: 35594736 PMCID: PMC9755220 DOI: 10.1016/j.thromres.2022.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Revised: 04/22/2022] [Accepted: 05/03/2022] [Indexed: 01/12/2023]
Abstract
Anticoagulation with Vitamin K antagonists (VKA) has always posed challenges in terms of monitoring requirements. These challenges were further exacerbated in the setting of the COVID-19 pandemic, with limited access to and/or avoidance of laboratory testing. The importance of utilizing point of care (POC) health technology for individualized patient management is salient. The foundation of effective home INR monitoring is establishing patient knowledge about their therapy and INR testing proficiency. The eKITE series was developed to support patients in establishing foundational knowledge required for VKA (warfarin) management and INR monitoring. The primary objectives were to evaluate eKITE, a patient-oriented innovative online education program for warfarin therapy, participant learning stress, and patient preference for online learning. This multi-center prospective study provided patients access to warfarin online education. Participants were required to complete written quizzes assessing warfarin knowledge of key concepts proficiency and identifying knowledge deficits. Patient preference, evaluating calm (lack of anxiety) while learning, and an INR on a home meter was completed. Participants performed INR tests at home and reported INRs by telephone. The analysis included 144 children and caregivers enrolled at five US and CDN sites. Most indications for anticoagulation were cardiac (congenital or acquired heart disease) with varied INR target ranges. Mean knowledge scores for warfarin and INR self-testing modules were 97%, with low anxiety with TTR of 84%. Patient preferred online learning. eKITE is an effective teaching modality for warfarin/home INR monitoring with safe INR testing and warfarin management that is appropriate for pediatrics and adults alike. PROLOGUE: The whir in the hallways is deafening. Lights bright, alarms are ringing in a chorus of unsynchronized beeps and screeches. It has been more than a week since I have slept. Snuggled beside me is my precious child, whining and equally irritated with the asynchronous symphony, further compounded by anxiety, procedures, and pain. The sun has broken. The staff smiles are welcoming and incessant, as one after one, they approach hurried, urgent, assiduous, their need to coach me for our upcoming departure to the warmth of home. Each provides essential information that I will require to keep my child, my treasure, safe and healthy. Yet, my eyes are heavy, blurred, and my brain foggy, trapped in a dark heavy cloud. How am I to follow? Comprehend? and retain anything? As they instruct, my precious child yearns for loving arms, compassion and love, whining, crying in disquiet. Overwhelmed does not adequately describe my ineffable exhaustion. Amidst this, how am I to learn about warfarin? Such a challenging medication, with so much to know. Concentrate, I tell myself, focus; now is my only opportunity to learn. I must be alert. It seems to be nonsensical.
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Affiliation(s)
- M.E. Bauman
- Stollery Children's Hospital, University of Alberta, Edmonton, AB, Canada,Corresponding author at: KidClot Pediatric Thrombosis Program, University of Alberta, Stollery Children's Hospital, 3-585 ECHA, 11405-87 Ave NW, Edmonton, Alberta T6G 1C9, Canada
| | | | | | - R. Bhat
- Division of Hematology/Oncology/Stem Cell Transplant, Lurie Children's Hospital of Chicago, Northwestern University, Chicago, IL, USA
| | - E. Simpson
- Children's Hospital of Eastern Ontario, ON, Canada
| | | | - P. Knox
- Alberta Children's Hospital, Canada
| | - M.P. Massicotte
- Stollery Children's Hospital, University of Alberta, Edmonton, AB, Canada
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Dhippayom T, Boonpattharatthiti K, Thammathuros T, Dilokthornsakul P, Sakunrag I, Devine B. Clinical Outcomes of Different Warfarin Self-Care Strategies: A Systematic Review and Network Meta-Analysis. Thromb Haemost 2022; 122:492-505. [PMID: 34695873 DOI: 10.1055/a-1677-9608] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
AIM To compare the effects of different strategies for warfarin self-care. METHODS PubMed, EMBASE, CENTRAL, CINAHL, ProQuest Dissertations & Theses, and OpenGrey were searched from inception to August 2021. Randomized controlled trials (RCTs) of warfarin self-care, either patient self-testing (PST) or patient self-management (PSM), were included. Self-care approaches were classified based on the TIP framework (theme, intensity, provider): (1) PST ≥1/week via e-Health (PST/High/e-Health); (2) PST ≥1/week by health care practitioner (PST/High/HCP); (3) PST <1/week via e-Health (PST/Low/e-Health); (4) PSM ≥1/week by e-Health (PSM/High/e-Health); (5) PSM ≥1/week by patient (PSM/High/Pt); (6) PSM <1/week by patient (PSM/Low/Pt); and (7) PSM with flexible frequency by patient (PSM/Flex/Pt). Mean differences (MDs) and risk ratios (RRs) with 95% confidence interval (CI) were estimated using frequentist network meta-analyses with a random-effects model. The certainty of evidence was evaluated using CINeMA (Confidence in Network Meta-Analysis). RESULTS Sixteen RCTs involving 5,895 participants were included. When compared with usual care, time in therapeutic range was higher in PSM/High/Pt and PST/High/e-Health with MD [95% CI] of 7.67% [0.26-15.08] and 5.65% [0.04-11.26], respectively. The certainty of evidence was rated as moderate for these findings. The risk of thromboembolic events was lower in the PSM/Flex/Pt group when compared with PST/High/e-Health (RR: 0.39 [0.20-0.77]) and usual care (RR: 0.38 [0.17-0.88]) with low and very low level of evidence, respectively. There was no significant difference in the proportion of international normalized ratio (INR) values in range, major bleeding, and all-cause mortality among different self-care features. CONCLUSION Patient self-care (either PST or PSM) by measuring INR values at least once weekly is more effective in controlling the INR level.
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Affiliation(s)
- Teerapon Dhippayom
- Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Naresuan University, Phitsanulok, Thailand
| | - Kansak Boonpattharatthiti
- Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Naresuan University, Phitsanulok, Thailand.,Division of Clinical Pharmacy, Faculty of Pharmaceutical Sciences, Burapha University, Chon Buri, Thailand
| | - Treeluck Thammathuros
- Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Naresuan University, Phitsanulok, Thailand
| | - Piyameth Dilokthornsakul
- Department of Pharmacy Practice, Center of Pharmaceutical Outcomes Research, Faculty of Pharmaceutical Sciences, Naresuan University, Phitsanulok, Thailand
| | - Itsarawan Sakunrag
- Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Naresuan University, Phitsanulok, Thailand
| | - Beth Devine
- The Comparative Health Outcomes, Policy, and Economics Institute, School of Pharmacy, University of Washington, Seattle, Washington, United States
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Leino AD, Park JM, Pasternak AL. Impact of CYP3A5 phenotype on tacrolimus time in therapeutic range and clinical outcomes in pediatric renal and heart transplant recipients. Pharmacotherapy 2021; 41:649-657. [PMID: 34129685 DOI: 10.1002/phar.2601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 06/01/2021] [Accepted: 06/02/2021] [Indexed: 11/11/2022]
Abstract
STUDY OBJECTIVE This study investigated the effect of CYP3A5 phenotype on time in therapeutic range (TTR) of tacrolimus post-transplant in pediatric patients. DESIGN AND DATA SOURCE This retrospective study assessed medical records of pediatric kidney and heart recipients with available CYP3A5 genotype for tacrolimus dosing, troughs, and the clinical events (biopsy-proven acute rejection [BPAR] and de novo donor-specific antibodies [dnDSA]). MEASUREMENTS AND MAIN RESULTS The primary outcome, mean TTR in the first 90 days post-transplant, was 9.0% (95% CI: -16.1, -1.9) lower in CYP3A5 expressers (p = 0.014) when adjusting for time to therapeutic concentration and organ type. There was no difference between CYP3A5 phenotypes in time to the first clinical event using TTR during the first 90 days. When applying TTR over the first year, there was a significant difference in event-free survival (EFS) which was 50.0% for CYP3A5 expressers/TTR < 35%, 45.5% for expressers/TTR ≥ 35%, 38.1% for nonexpressers/TTR < 35%, and 72.9% for nonexpressers/TTR ≥ 35% (log-rank p = 0.03). A post hoc analysis of EFS identified CYP3A5 expressers had lower EFS compared to nonexpressers in patients with TTR ≥ 35% (p = 0.04) but no difference among patients with TTR < 35% (p = 0.6). CONCLUSIONS The relationship between TTR and CYP3A5 phenotype suggests that achieving a TTR ≥ 35% during the first year may be a modifiable factor to attenuate the risk of BPAR and dnDSA.
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Affiliation(s)
- Abbie D Leino
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
| | - Jeong M Park
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
| | - Amy L Pasternak
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
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Ahmed H, Saddouh EA, Abugrin ME, Ali AMM, Elgdhafi EO, Khaled A, Tarek A, Elhadi M. Association between Patients' Knowledge and Adherence to Anticoagulants, and Its Effect on Coagulation Control. Pharmacology 2020; 106:265-274. [PMID: 33202413 DOI: 10.1159/000511754] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 09/18/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Warfarin requires strict monitoring by measuring prothrombin time (PT), international normalized ratio (INR), and time in therapeutic range (TTR). Several factors can lead to poor PT/INR control including vitamin K status, medication adherence, knowledge, and quality of life. The present study aims to assess patient adherence to warfarin treatment and its correlation with INR control. METHODS A cross-sectional study was conducted between October 2017 and January 2018 at Tripoli University Hospital. Data were collected by structured questionnaires which included; demographic and clinical characteristics, the Oral Anticoagulation Knowledge (OAK) test, and the Morisky Medication Adherence Scale (MMAS-8). RESULTS The final analysis included 88 out of 140 patients (73.33%). There were significant differences in age range, gender, marital status, and education level between the 2 groups (poor knowledge and adequate knowledge) (p < 0.05). There was a significant positive correlation between OAK test score and TTR. Overall, 76.2% of patients were adherent to warfarin (MMAS score ≥6) and 20.45% of patients were of high adherence (MMAS score of 8). The median score was 6 (IQR 6-7). A statistically significant, strong positive correlation between adherence to medication and TTR as an indicator of INR control was found (rs[86] = 0.472, p < 0.0001). CONCLUSION The study addressed and identified several areas for future improvement of patient outcomes. The implementation of new approaches to enhance patient knowledge and adherence is warranted, and measures to provide treatment for all patients that require it are needed, to improve outcomes and decrease adverse drug effects.
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Affiliation(s)
- Hazem Ahmed
- Faculty of Medicine, University of Tripoli, Tripoli, Libya
| | | | | | | | | | - Ala Khaled
- Faculty of Medicine, University of Tripoli, Tripoli, Libya
| | - Ahmed Tarek
- Faculty of Medicine, University of Tripoli, Tripoli, Libya
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7
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Fung KP, Chan KH, Ng V, Tsui PT, You JHS. Health Economic Analysis of Rivaroxaban and Warfarin for Venous Thromboembolism Management in Chinese Patients. Cardiovasc Drugs Ther 2020; 33:331-337. [PMID: 30888571 DOI: 10.1007/s10557-019-06872-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE Rivaroxaban, a direct oral anticoagulant, has demonstrated non-inferiority to warfarin for venous thromboembolism (VTE) treatment in clinical trials. This study aimed to analyze the direct medical costs for VTE management with rivaroxaban versus warfarin in Hong Kong Chinese patients. METHODS In this retrospective observational study, VTE patients admitted to the Princess Margaret Hospital from March 2012 to February 2017 who were initiated and discharged with either rivaroxaban or warfarin were included. Patient demographic and clinical data, and healthcare resource utilization for VTE management were collected for the VTE index admission and 1-year post-discharge period. RESULTS A total of 181 patients (90 in the rivaroxaban group; 91 in the warfarin group) were included. The mean (± SD) length of stay (LOS) was 4.8 ± 2.7 days and 8.0 ± 3.0 days in the rivaroxaban and warfarin groups, respectively (p > 0.001). The total cost for VTE index admission in the rivaroxaban group was significantly lower than that of the warfarin group (USD 5473 ± 1914 versus USD 3457 ± 1796; p < 0.001) (USD 1 = HKD 7.8). Recurrent VTE and bleeding rates in 1-year post-discharge period were not significantly different between the two groups. The direct total cost of the rivaroxaban group (USD 1271 ± 767) was significantly lower than that of the warfarin group (USD 1739 ± 1045) in 1-year post-discharge period (p < 0.001). CONCLUSIONS Total direct cost and LOS for VTE admission and total cost in 1-year post-discharge period were significantly lower in patients initiated and discharged with rivaroxaban than those of warfarin.
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Affiliation(s)
- Ka-Po Fung
- School of Pharmacy, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, N.T., Hong Kong SAR, China.,Pharmacy Department, Princess Margaret Hospital, Hong Kong SAR, China
| | - Kei-Hong Chan
- School of Pharmacy, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, N.T., Hong Kong SAR, China.,Pharmacy Department, Princess Margaret Hospital, Hong Kong SAR, China
| | - Vivien Ng
- Pharmacy Department, Princess Margaret Hospital, Hong Kong SAR, China
| | - Ping-Tim Tsui
- Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong SAR, China
| | - Joyce H S You
- School of Pharmacy, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, N.T., Hong Kong SAR, China.
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Sargin M, Erdogan SB, Bastopcu M, Arslanhan G, Tasdemir MM, Orhan G. Cost of Healthcare Associated With Deep Vein Thrombosis in Patients Treated With Warfarin in Turkey: 2010-2013 Database Analysis of a Tertiary Care Center. Value Health Reg Issues 2019; 19:81-86. [PMID: 31254969 DOI: 10.1016/j.vhri.2019.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Revised: 01/22/2019] [Accepted: 03/08/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVES To evaluate the cost of healthcare with respect to the quality of anticoagulation in patients with deep vein thrombosis (DVT) treated with warfarin in daily practice via the database analysis of a tertiary care center in the period 2010 to 2013. METHODS Of 258 307 records in total, 42 582 unique patients with DVT and 32 012 patients with international normalized ratio (INR) measurements were included. Overall, 6720 unique patients with DVT diagnosis and one or more INR measurements were identified, and the records of 4377 out of 6720 unique patients were validated and included in the analysis data set. The cost analysis was based on direct medical costs from the payer's perspective. Cost items were related to healthcare resource utilization (inpatient and outpatient services) during the study period, which provided a basis for calculation of per-patient, outpatient, inpatient, and total direct medical costs. RESULTS Mean outpatient, inpatient, and total hospital admission costs were $578, $2195, and $2785, respectively, for patients with time in the therapeutic range of 70% or more, whereas the same costs were $571, $2163, and $3192, respectively, for patients with time in the therapeutic range of less than 70%. CONCLUSIONS Our findings for a retrospective cohort of patients with DVT undergoing warfarin therapy reveal that patients spent 70% or more, as opposed to less than 70%, of follow-up time within the therapeutic INR range and that outpatient care, as opposed to inpatient care, was associated with lower healthcare costs. Given the significant contribution that hospital stay makes to the cost burden of DVT, our findings also highlight the association between poor warfarin anticoagulant control and increased hospitalization costs.
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Affiliation(s)
- Murat Sargin
- Department of Cardiovascular Surgery, Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey.
| | - Sevinc Bayer Erdogan
- Department of Cardiovascular Surgery, Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Murat Bastopcu
- Department of Cardiovascular Surgery, Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Gokhan Arslanhan
- Department of Cardiovascular Surgery, Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Muge Mete Tasdemir
- Department of Cardiovascular Surgery, Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Gokcen Orhan
- Department of Cardiovascular Surgery, Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
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9
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Solano MH. Experiencia de validación de material educativo pacientes anticoagulados en un servicio de consulta externa. REPERTORIO DE MEDICINA Y CIRUGÍA 2019. [DOI: 10.31260/repertmedcir.v28.n2.2019.917] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
La terapia con anticoagulantes está indicada en los procesos trombóticos y requieren un manejo integral para reducir los eventos adversos. Las medidas para el seguimiento incluyen monitorización, vigilancia y educación continua creando alternativas pedagógicas que facilitan los procesos de recepción y apropiación de la información. Objetivo: validar el material educativo para el paciente anticoagulado asistente al servicio de hematología. Metodología: la experiencia se desarrolló en tres fases: búsqueda bibliográfica, construcción y diseño del material educativo, y validación. Para esta fase se realizaron dos procesos, uno de validación técnica y otro con la comunidad. Resultados: se identificaron 19 documentos, ninguno reportó procesos de validación. Con base en la documentación analizada se consideró que el material más adecuado para la población era una cartilla educativa. Discusión: los materiales educativos para pacientes son una herramienta utilizada con frecuencia por el sistema de salud, como complemento de la atención que se realiza por fuera de la consulta médica, pero son escasos los procesos de validación rigurosa de este tipo de material en el área de hematología.
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10
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Shah BR, Scholtus E, Rolland C, Batscheider A, Katz JN, Nilsson KR. A rapid evidence assessment of bleed-related healthcare resource utilization in publications reporting the use of direct oral anticoagulants for non-valvular atrial fibrillation. Curr Med Res Opin 2019; 35:127-139. [PMID: 30380959 DOI: 10.1080/03007995.2018.1543184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Objective: Non-valvular atrial fibrillation (NVAF), a common cardiac arrhythmia, is associated with high morbidity and carries a substantial economic burden. Historically, vitamin K antagonists (VKAs; e.g. warfarin) have been used for therapy of NVAF, but recently several direct oral anticoagulants (DOACs) have been approved for prevention of stroke in patients with NVAF. This review summarizes the real-world evidence (RWE) for healthcare resource utilization (HRU) in patients receiving oral anticoagulants (VKAs and/or DOACs) for therapy of NVAF.Methods: A PRISMA-compliant literature search assessed Medline® and Embase® databases from 1 January 2011 to 4 May 2017, and the National Health Service Economic Evaluation Database from 1 January 2011 to 31 December 2015. Publications were included if they reported observational data from real-world use of one or more anticoagulant therapies. Outcomes of interest included hospitalizations, length of stay (LOS), mortality and costs.Results: Twenty-eight publications were included. Apixaban and dabigatran were associated with fewer bleed-related hospitalizations than warfarin. Bleed-related LOS were generally longer for warfarin than for DOACs. Bleed-related treatment costs were lower for patients receiving apixaban or receiving dabigatran than patients receiving rivaroxaban or receiving warfarin. Bleed-related mortality in patients receiving oral anticoagulation for treatment of NVAF were low across all DOACs and warfarin.Conclusions: The limited available evidence for HRU burden among patients receiving oral anticoagulation for NVAF suggests that DOACs (particularly apixaban and dabigatran) offer some degree of benefit in terms of HRU outcomes, compared with warfarin. Further work is required to understand HRU outcomes in patients receiving DOACs.
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Affiliation(s)
- Bimal R Shah
- Livongo Health, Mountain View, CA, USA
- Department of Medicine, Duke University, Durham, NC, USA
| | | | | | | | - Jason N Katz
- Divisions of Cardiology and Pulmonary/Critical Care Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Kent R Nilsson
- Piedmont Heart Institute, Piedmont Athens Regional & Augusta University - University of Georgia Medical Partnership, Athens, GA, USA
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11
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Saksena D, Mishra YK, Muralidharan S, Kanhere V, Srivastava P, Srivastava CP. Follow-up and management of valvular heart disease patients with prosthetic valve: a clinical practice guideline for Indian scenario. Indian J Thorac Cardiovasc Surg 2019; 35:3-44. [PMID: 33061064 PMCID: PMC7525528 DOI: 10.1007/s12055-019-00789-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
PURPOSE Valvular heart disease (VHD) patients after prosthetic valve implantation are at risk of thromboembolic events. Follow-up care of patients with prosthetic valve has a paramount role in reducing the morbidity and mortality. Currently, in India, there is quintessential need to stream line the follow-up care of prosthetic valve patients. This mandates the development of a consensus guideline for the antithrombotic therapy in VHD patients post prosthetic valve implantation. METHODS A national level panel was constituted comprising 13 leading cardio care experts in India who thoroughly reviewed the up to date literature, formulated the recommendations, and developed the consensus document. Later on, extensive discussions were held on this draft and the recommendations in 8 regional meetings involving 79 additional experts from the cardio care in India, to arrive at a consensus. The final consensus document is developed relying on the available evidence and/or majority consensus from all the meetings. RESULTS The panel recommended vitamin K antagonist (VKA) therapy with individualized target international normalized ratio (INR) in VHD patients after prosthetic valve implantation. The panel opined that management of prosthetic valve complications should be personalized on the basis of type of complications. In addition, the panel recommends to distinguish individuals with various co-morbidities and attend them appropriately. CONCLUSIONS Anticoagulant therapy with VKA seems to be an effective option post prosthetic valve implantation in VHD patients. However, the role for non-VKA oral therapy in prosthetic valve patients and the safety and efficacy of novel oral anticoagulants in patients with bioprosthetic valve need to be studied extensively.
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Pengo V, Denas G. Optimizing quality care for the oral vitamin K antagonists (VKAs). HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2018; 2018:332-338. [PMID: 30504329 PMCID: PMC6245991 DOI: 10.1182/asheducation-2018.1.332] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
Vitamin K antagonists (VKAs) have been the only oral anticoagulants for decades. The management of anticoagulant therapy with VKA is challenging because of the intricate pharmacological properties of these agents. The success of VKA therapy depends on the quality of treatment that is ensured through continuing comprehensive communication and education. The educational program should address important issues of the VKA therapy such as beginning of treatment, pharmacological, dietary, and drug-drug interactions, as well as treatment temporary suspension during surgical interventions or invasive maneuvers. In addition, the initial and continuing patient education is of imperative importance. A major role in the educational process may be addressed by patient associations. The quality of treatment is better reached if patients are followed in anticoagulation clinics. Moreover, a federation of anticoagulation clinics may improve patient care through regular meetings to update knowledge on VKA treatment. Learning objectives of this paper is to allow readers to correctly approach patients starting VKA treatment, recognize possible pitfalls of treatment, and provide adequate solutions.
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Affiliation(s)
- Vittorio Pengo
- Cardiology Clinic, Thrombosis Centre, University of Padua, Padua, Italy
| | - Gentian Denas
- Cardiology Clinic, Thrombosis Centre, University of Padua, Padua, Italy
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Sargin M, Tasdemir MM, Kuplay H, Erdogan SB, Tandogar N, Akansel S, Kurc E, Orhan G, Aka SA. Retrospective cohort study for evaluating the INR monitoring patterns in patients with deep vein thrombosis in daily practice: Analysis of 2010-2013 database of a tertiary care center. Phlebology 2018; 34:317-323. [PMID: 30336760 DOI: 10.1177/0268355518806117] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To evaluate the international normalized ratio (INR) monitoring patterns in patients with deep vein thrombosis. METHODS Of 32,012 patients with ≥1 outpatient INR measurement and 42,582 patients with confirmed deep vein thrombosis diagnosis registered to our hospital between 1 January 2010 and 31 December 2013, 6720 records were identified to have both deep vein thrombosis and international normalized ratio measurement, and 4.377 out of 6.720 single patient records were determined to be statistically analyzable. RESULTS Median INR measurement frequency was 6.47 times/year and patients had INR levels of 2-3 in 34.3% of follow-up time. Having ≥70% vs. <70% of follow-up time within therapeutic range was associated with lower hospital admission frequency (9.7 vs. 10.3 times/year). CONCLUSION Our study revealed only one-third of the follow-up time to be spent within therapeutic INR, association of INR therapeutic range with lesser number of hospital admissions and INR monitoring frequency of 6.47 times/year despite lack of stable INR control in most of the deep vein thrombosis patients.
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Affiliation(s)
- Murat Sargin
- Department of Cardiovascular Surgery, Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Muge Mete Tasdemir
- Department of Cardiovascular Surgery, Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Huseyin Kuplay
- Department of Cardiovascular Surgery, Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Sevinc Bayer Erdogan
- Department of Cardiovascular Surgery, Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Nehir Tandogar
- Department of Cardiovascular Surgery, Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Serdar Akansel
- Department of Cardiovascular Surgery, Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Erol Kurc
- Department of Cardiovascular Surgery, Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Gokcen Orhan
- Department of Cardiovascular Surgery, Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Serap Aykut Aka
- Department of Cardiovascular Surgery, Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
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Nagata N, Yasunaga H, Matsui H, Fushimi K, Watanabe K, Akiyama J, Uemura N, Niikura R. Therapeutic endoscopy-related GI bleeding and thromboembolic events in patients using warfarin or direct oral anticoagulants: results from a large nationwide database analysis. Gut 2018; 67:1805-1812. [PMID: 28874418 PMCID: PMC6145295 DOI: 10.1136/gutjnl-2017-313999] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Revised: 06/19/2017] [Accepted: 07/30/2017] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To compare the risks of postendoscopy outcomes associated with warfarin with direct oral anticoagulants (DOACs), taking into account heparin bridging and various types of endoscopic procedures. DESIGN Using the Japanese Diagnosis Procedure Combination database, we identified 16 977 patients who underwent 13 types of high-risk endoscopic procedures and took preoperative warfarin or DOACs from 2014 to 2015. One-to-one propensity score matching was performed to compare postendoscopy GI bleeding and thromboembolism between the warfarin and DOAC groups. RESULTS In the propensity score-matched analysis involving 5046 pairs, the warfarin group had a significantly higher proportion of GI bleeding than the DOAC group (12.0% vs 9.9%; p=0.002). No significant difference was observed in thromboembolism (5.4% vs 4.7%) or in-hospital mortality (5.4% vs 4.7%). The risks of GI bleeding and thromboembolism were greater in patients treated with warfarin plus heparin bridging or DOACs plus bridging than in patients treated with DOACs alone. Compared with percutaneous endoscopic gastrostomy, patients who underwent endoscopic submucosal dissection, endoscopic mucosal resection and haemostatic procedures including endoscopic variceal ligation or endoscopic injection sclerotherapy were at the highest risk of GI bleeding among the 13 types of endoscopic procedures, whereas those who underwent lower polypectomy endoscopic sphincterotomy or endoscopic ultrasound-guided fine needle aspiration were at moderate risk. CONCLUSION The risk of postendoscopy GI bleeding was higher in warfarin than DOAC users. Heparin bridging was associated with an increased risk of bleeding and did not prevent thromboembolism. The bleeding risk varied by the type of endoscopic procedure.
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Affiliation(s)
- Naoyoshi Nagata
- Department of Gastroenterology and Hepatology, National Center for Global health and Medicine, Tokyo, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Kiyohide Fushimi
- Department of Health Care Informatics, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kazuhiro Watanabe
- Department of Gastroenterology and Hepatology, National Center for Global health and Medicine, Tokyo, Japan
| | - Junichi Akiyama
- Department of Gastroenterology and Hepatology, National Center for Global health and Medicine, Tokyo, Japan
| | - Naomi Uemura
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Kohnodai Hospital, Chiba, Japan
| | - Ryota Niikura
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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Lee TC, Qian M, Lip GY, Di Tullio MR, Graham S, Mann DL, Nakanishi K, Teerlink JR, Freudenberger RS, Sacco RL, Mohr J, Labovitz AJ, Ponikowski P, Lok DJ, Estol C, Anker SD, Pullicino PM, Buchsbaum R, Levin B, Thompson JL, Homma S, Ye S. Heart Failure Severity and Quality of Warfarin Anticoagulation Control (From the WARCEF Trial). Am J Cardiol 2018; 122:821-827. [PMID: 30037426 DOI: 10.1016/j.amjcard.2018.05.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Revised: 05/07/2018] [Accepted: 05/07/2018] [Indexed: 01/06/2023]
Abstract
Previous studies in patients with atrial fibrillation showed that a history of heart failure (HF) could negatively impact anticoagulation quality, as measured by the average time in therapeutic range (TTR). Whether additional markers of HF severity are associated with TTR has not been investigated thoroughly. We aimed to examine the potential role of HF severity in the quality of warfarin control in patients with HF with reduced ejection fraction. Data from the Warfarin versus Aspirin in Reduced Cardiac Ejection Fraction Trial were used to investigate the association between TTR and HF severity. Multivariable logistic regression models were used to examine the association of markers of HF severity, including New York Heart Association (NYHA) class, Minnesota Living with HF (MLWHF) score, and frequency of HF hospitalization, with TTR ≥70% (high TTR). We included 1,067 participants (high TTR, N = 413; low TTR, N = 654) in the analysis. In unadjusted analysis, patients with a high TTR were older and less likely to have had strokes or receive other antiplatelet agents. Those patients also had lower NYHA class, better MLWHF scores, greater 6-minute walk distance, and lower frequency of HF hospitalizations. Multivariable analysis showed that NYHA class III and/or IV (Odds ratio [OR] 0.68 [95% confidence intervals [CIs] 0.49 to 0.94]), each 10-point increase in MLWHF score (i.e., worse health-related quality of life) (OR 0.92 [0.86 to 0.99]), and higher number of HF hospitalization per year (OR0.45 [0.30 to 0.67]) were associated with decreased likelihood of having high TTR. In HF patients with systolic dysfunction, NYHA class III and/or IV, poor health-related quality of life, and a higher rate of HF hospitalization were independently associated with suboptimal quality of warfarin anticoagulation control. These results affirm the need to assess the new approaches, such as direct oral anticoagulants, to prevent thromboembolism in this patient population.
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Sudas Na Ayutthaya N, Sakunrak I, Dhippayom T. Clinical Outcomes of Telemonitoring for Patients on Warfarin after Discharge from Hospital. Int J Telemed Appl 2018; 2018:7503421. [PMID: 30158972 PMCID: PMC6109538 DOI: 10.1155/2018/7503421] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 07/13/2018] [Accepted: 07/26/2018] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE To evaluate the impact of telephone follow-up service on clinical outcomes in patients on warfarin when discharged from hospital. METHODS This randomized controlled trial was conducted at a general hospital in Thailand. Patients aged ≥20 years who were prescribed warfarin when discharged were eligible to participate in this study. They were randomly allocated, using a computer generated random number, to receive either telephone follow-up intervention or usual care. Participants in the intervention group received telephone follow-up by hospital pharmacists for three months. During each telephone call, pharmacists performed medicine use reviews and addressed any problems identified. KEY FINDINGS A total of 50 patients participated in this study. The proportion of international normalized ratio (INR) values in the target range for the telephone follow-up group (36/79, 45.6%) was higher than that in the usual care group (19/79, 24.1%), p=0.005. The mean time in the therapeutic range (TTR) in the telephone follow-up group was also higher than that in the usual care group (49.8±34.3 versus 28.0±27.5, p=0.017). All patients in the usual care group experienced one or more out-of-range INR values (25/25, 100%) compared to 21 out of 25 (84%) in the telephone follow-up group, p=0.037. There was no difference between the two groups in the incidence of complications or adverse events associated with warfarin. CONCLUSIONS The telephone follow-up service in recently discharged patients helps them achieve and maintain their INR target. This anticoagulant supportive service should be promoted to patients receiving warfarin therapy after discharge. This trial is registered with TCTR20180614006 (Thai Clinical Trials Registry).
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Affiliation(s)
- Natthaporn Sudas Na Ayutthaya
- Department of Pharmacy, Kamphaeng Phet Hospital, Mueang Kamphaeng Phet, Thailand
- Faculty of Pharmaceutical Sciences, Naresuan University, Phitsanulok, Thailand
| | - Itsarawan Sakunrak
- Faculty of Pharmaceutical Sciences, Naresuan University, Phitsanulok, Thailand
| | - Teerapon Dhippayom
- Faculty of Pharmaceutical Sciences, Naresuan University, Phitsanulok, Thailand
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Yanagisawa N, Nagata N, Watanabe K, Iida T, Hamada M, Kobayashi S, Shimbo T, Akiyama J, Uemura N. Post-polypectomy bleeding and thromboembolism risks associated with warfarin vs direct oral anticoagulants. World J Gastroenterol 2018; 24:1540-1549. [PMID: 29662292 PMCID: PMC5897858 DOI: 10.3748/wjg.v24.i14.1540] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 03/15/2018] [Accepted: 03/25/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To verify the validity of the endoscopy guidelines for patients taking warfarin or direct oral anticoagulants (DOAC). METHODS We collected data from 218 patients receiving oral anticoagulants (73 DOAC users, 145 warfarin users) and 218 patients not receiving any antithrombotics (age- and sex-matched controls) who underwent polypectomy. (1) We evaluated post-polypectomy bleeding (PPB) risk in patients receiving warfarin or DOAC compared with controls; (2) we assessed the risks of PPB and thromboembolism between three AC management methods: Discontinuing AC with heparin bridge (HPB) (endoscopy guideline recommendation), continuing AC, and discontinuing AC without HPB. RESULTS PPB rate was significantly higher in warfarin users and DOAC users compared with controls (13.7% and 13.7% vs 0.9%, P < 0.001), but was not significantly different between rivaroxaban (13.2%), dabigatran (11.1%), and apixaban (13.3%) users. Two thromboembolic events occurred in warfarin users, but none in DOAC users. Compared with the continuing anticoagulant group, the discontinuing anticoagulant with HPB group (guideline recommendation) had a higher PPB rate (10.8% vs 19.6%, P = 0.087). These findings were significantly evident in warfarin but not DOAC users. One thrombotic event occurred in the discontinuing anticoagulant with HPB group and the discontinuing anticoagulant without HPB group; none occurred in the continuing anticoagulant group. CONCLUSION PPB risk was similar between patients taking warfarin and DOAC. Thromboembolism was observed in warfarin users only. The guideline recommendations for HPB should be re-considered.
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Affiliation(s)
- Naohiro Yanagisawa
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo 162-8655, Japan
| | - Naoyoshi Nagata
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo 162-8655, Japan
| | - Kazuhiro Watanabe
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo 162-8655, Japan
| | - Tatsuhiro Iida
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo 162-8655, Japan
| | - Mariko Hamada
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo 162-8655, Japan
| | - Sakurako Kobayashi
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo 162-8655, Japan
| | - Takuro Shimbo
- Ohta Nishinouchi Hospital, Fukushima 963-8022, Japan
| | - Junichi Akiyama
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo 162-8655, Japan
| | - Naomi Uemura
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Kohnodai Hospital, Chiba 272-8516, Japan
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What is the importance of real-time three dimensional transesophageal echocardiography and time in therapeutic range in patients with prosthetic valve thrombosis? J Thromb Thrombolysis 2018; 46:79-80. [PMID: 29633067 DOI: 10.1007/s11239-018-1655-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Davis S, Gralla J, Klem P, Tong S, Wedermyer G, Freed B, Wiseman A, Cooper JE. Lower tacrolimus exposure and time in therapeutic range increase the risk of de novo donor-specific antibodies in the first year of kidney transplantation. Am J Transplant 2018; 18:907-915. [PMID: 28925597 PMCID: PMC5858995 DOI: 10.1111/ajt.14504] [Citation(s) in RCA: 90] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Revised: 08/31/2017] [Accepted: 09/04/2017] [Indexed: 02/07/2023]
Abstract
De novo donor-specific antibodies (dnDSAs) have been associated with reduced graft survival. Tacrolimus (TAC)-based regimens are the most common among immunosuppressive approaches used in in clinical practice today, yet an optimal therapeutic dose to prevent dnDSAs has not been established. We evaluated mean TAC C0 (tacrolimus trough concentration) and TAC time in therapeutic range for the risk of dnDSAs in a cohort of 538 patients in the first year after kidney transplantation. A mean TAC C0 < 8 ng/mL was associated with dnDSAs by 6 months (odds ratio [OR] 2.51, 95% confidence interval [CI] 1.32-4.79, P = .005) and by 12 months (OR 2.32, 95% CI 1.30-4.15, P = .004), and there was a graded increase in risk with lower mean TAC C0 . TAC time in the therapeutic range of <60% was associated with dnDSAs (OR 2.05, 95% CI 1.28-3.30, P = .003) and acute rejection (hazard ratio [HR] 4.18, 95% CI 2.31-7.58, P < .001) by 12 months and death-censored graft loss by 5 years (HR 3.12, 95% CI 1.53-6.37, P = .002). TAC minimization may come at a cost of higher rates of dnDSAs, and TAC time in therapeutic range may be a valuable strategy to stratify patients at increased risk of adverse outcomes.
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Affiliation(s)
- Scott Davis
- Division of Renal Diseases and Hypertension, University of Colorado Anschutz Medical Campus
| | - Jane Gralla
- Department of Pediatrics, University of Colorado Anschutz Medical Campus
| | - Patrick Klem
- Department of Pharmacy, University of Colorado Anschutz Medical Campus
| | - Suhong Tong
- Department of Pediatrics, University of Colorado Anschutz Medical Campus
| | - Gina Wedermyer
- Clinimmune Labs, University of Colorado Anschutz Medical Campus
| | - Brian Freed
- Department of Pediatrics, University of Colorado Anschutz Medical Campus
| | - Alexander Wiseman
- Division of Renal Diseases and Hypertension, University of Colorado Anschutz Medical Campus
| | - James E. Cooper
- Division of Renal Diseases and Hypertension, University of Colorado Anschutz Medical Campus
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Cosansu K, Vatan MB, Gunduz H, Akdemir R. Use of neutrophil-lymphocyte ratio for risk stratification and relationship with time in therapeutic range in patients with nonvalvular atrial fibrillation: A pilot study. Clin Cardiol 2018; 41:339-342. [PMID: 29569402 DOI: 10.1002/clc.22869] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Revised: 11/23/2017] [Accepted: 12/07/2017] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Atrial fibrillation is one of the most common abnormal heart rhythms. Neutrophil-lymphocyte ratio (NLR) has emerged as a potential marker for the level of inflammation in cardiac disorders. HYPOTHESIS NLR might be associated with thrombosis and bleeding risk scores and might predict cardioembolic risk in nonvalvular atrial fibrillation (NVAF) patients within the therapeutic international normalized ratio (INR). METHODS We enrolled 272 patients taking warfarin for NVAF and classified them into 2 groups: Group A consisted of patients (n = 132) whose time in therapeutic range (TTR) was ≥65%, and Group B comprised patients (n = 139) whose TTR was <65%. RESULTS NLR values were higher in group B than in group A (P < 0.0001). Patients classified as high risk according to CHA2 DS2 -VASc score had significantly higher NLR levels (P = 0.002) than those classified as low and intermediate risk. Furthermore, NLR levels were significantly correlated with CHA2 DS2 -VASc and HAS-BLED scores (P < 0.001 and P < 0.0001, respectively). NLR predicted patients within therapeutic INR range (TTR ≥65%) with sensitivity of 81% and specificity of 71% in a receiver operator characteristic curve analysis, using a cutoff value of 2.17. Area under the curve for NLR was 0.81 (P < 0.0001). CONCLUSIONS To our knowledge, this is the first study showing correlation of NLR with both CHA2 DS2 -VASc and HAS-BLED risk scores. NLR might represent a useful marker to identify patients with high risks of stroke and bleeding and may have predictive value in identifying patients within the therapeutic INR range.
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Affiliation(s)
- Kahraman Cosansu
- Department of Cardiology, Education and Research Hospital, Sakarya University, Sakarya, Turkey
| | - Mehmet Bulent Vatan
- Department of Cardiology, Education and Research Hospital, Sakarya University, Sakarya, Turkey
| | - Huseyin Gunduz
- Department of Cardiology, Education and Research Hospital, Sakarya University, Sakarya, Turkey
| | - Ramazan Akdemir
- Department of Cardiology, Education and Research Hospital, Sakarya University, Sakarya, Turkey
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ten Cate H. Monitoring new oral anticoagulants, managing thrombosis, or both? Thromb Haemost 2017; 107:803-5. [DOI: 10.1160/th12-03-0130] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2012] [Accepted: 03/06/2012] [Indexed: 11/05/2022]
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Thanimalai S, Shafie AA, Ahmad Hassali MA, Sinnadurai J. Cost-Effectiveness of Warfarin Medication Therapy Adherence Clinic versus Usual Medical Clinic at Kuala Lumpur Hospital. Value Health Reg Issues 2017; 15:34-41. [PMID: 29474176 DOI: 10.1016/j.vhri.2017.05.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Revised: 04/04/2017] [Accepted: 05/30/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Systematic anticoagulation management clinic is recommended to manage patients on chronic warfarin therapy. In Malaysia, the service was introduced as warfarin medication therapy adherence clinic (WMTAC), which is managed by pharmacists with a physician advisory. OBJECTIVES To assess the cost-effectiveness of WMTAC in comparison with usual medical clinic (UMC), which is managed by medical officers in Kuala Lumpur Hospital, a tertiary referral hospital in Malaysia. METHODS Data from a 6-month retrospective cohort study comparing the two clinics and the mean percentages of time in the therapeutic range for the patients were used to estimate the cost-effectiveness. The mean clinic costs were estimated using the time-motion study. A Markov model with a 6-monthly cycle was used to simulate lifetime cost-effectiveness from the perspective of the health care service provider. The base-case analysis assumed a cohort of patients with atrial fibrillation, 57 years of age with comorbid illnesses. The transition probabilities of these clinic outcomes were obtained from a literature search. Future costs and effectiveness were discounted by 3% to convert to present values. All costs were in Malaysian ringgit standardized for the year 2007. RESULTS The mean 6-month treatment cost was lower for the WMTAC, which was significantly lower (P < 0.001). The UMC was found to be dominated by the WMTAC for both intermediate and lifetime analyses. The sensitivity analysis showed that clinic consultation costs had a major impact on the cost-effectiveness analysis. CONCLUSIONS WMTAC is a more cost-effective option than UMC in Kuala Lumpur Hospital.
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Affiliation(s)
- Subramaniam Thanimalai
- Universiti Sains Malaysia, Penang, Malaysia; Ministry of Health Malaysia, Putrajaya, Malaysia
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Fenta TG, Assefa T, Alemayehu B. Quality of anticoagulation management with warfarin among outpatients in a tertiary hospital in Addis Ababa, Ethiopia: a retrospective cross-sectional study. BMC Health Serv Res 2017; 17:389. [PMID: 28587606 PMCID: PMC5461683 DOI: 10.1186/s12913-017-2330-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Accepted: 05/22/2017] [Indexed: 11/10/2022] Open
Abstract
Background Warfarin is the most widely used anticoagulant in the world. The difficulty of managing warfarin contributes to great potential for patient harm, both from excessive anticoagulation and insufficient anticoagulation. This study assessed the International Normalized Ratio (INR) control outcome measures and warfarin dose adjustment practices at cardiology and hematology outpatient clinics at a teaching hospital in Addis Ababa, Ethiopia. Methods The study was based on a cross - sectional study design involving 360 retrospective patients’ chart review among outpatients who received warfarin for its various indications. Results The mean frequency of INR monitoring per patient was 62.9 days (17.2–143.7 days). Patients spent 52.2%, 29.0% and 18.8% of the time in sub-therapeutic, therapeutic and supra-therapeutic ranges, respectively. The daily warfarin dose was increased 50.9% and 36.9% and decreased in 52.8% and 60.9% of the time for occurrences of sub-therapeutic and supra-therapeutic INRs to achieve target ranges of 2.0–3.0 and 2.5–3.5, respectively. Conclusion The quality of anticoagulation management with warfarin among outpatients in Tikur Anbessa Specialized Hospital was sub-optimal. This was reflected by low Time in Therapeutic Range (TTR), longer than recommended INR monitoring frequency, and minimal actions taken to adjust warfarin dose after occurrences of non-therapeutic INRs.
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Affiliation(s)
- Teferi Gedif Fenta
- School of Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.
| | - Tamrat Assefa
- School of Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Bekele Alemayehu
- School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
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Kalçık M, Yesin M, Gürsoy MO, Gündüz S, Karakoyun S, Astarcıoğlu MA, Bayam E, Cerşit S, Özkan M. Comparison of the INR Values Measured by CoaguChek XS Coagulometer and Conventional Laboratory Methods in Patients on VKA Therapy. Clin Appl Thromb Hemost 2016; 23:187-194. [PMID: 26177662 DOI: 10.1177/1076029615595881] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Warfarin, which is a widely used oral anticoagulant, has a narrow therapeutic window and requires regular international normalized ratio (INR) monitoring to maintain optimal anticoagulation. Recently, several portable coagulometers have been developed to measure INR levels. OBJECTIVE To compare the INR results obtained by a portable coagulometer (CoaguChek XS) and a standard laboratory method (STAGO STA-R). METHODS Overall, 433 consecutive patients (male: 191, median age: 61 [44-86] years) who were admitted to outpatient anticoagulation clinic were enrolled in this study. Each patient was tested for INR using portable CoaguChek XS and STAGO STA-R automatic laboratory coagulometer. Correlation between methods was assessed using the Pearson correlation test and Cohen κ test. Bland-Altman plot was used to identify mean difference and 95% limits of agreement. RESULTS The mean INR values for CoaguChek XS and STAGO STA-R were 2.54 ± 1.17 and 2.79 ± 1.39, respectively. There was a strong positive correlation between the 2 methods ( r = .966; 95% confidence interval [CI]: 0.95-0.97, P < .001). The Bland-Altman analysis gave a mean difference of 0.26 ± 0.40 between the 2 methods, with a 95% limit of agreement of -0.54 to 1.05. In patients with INR values >5.0, there was only a moderate correlation ( r = .676; 95% CI: 0.38-0.89, P = .002), and the mean difference of INR tended to increase as mean INR values increased. There was a high overall agreement between the 2 methods (κ = .751; 95% CI: 0.69-0.80; P < .001). CONCLUSION There was good consistency between traditional laboratory testing and CoaguChek XS coagulometer, which provides rapid and reliable INR analysis.
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Affiliation(s)
- Macit Kalçık
- 1 Department of Cardiology, Kosuyolu Kartal Heart Training and Research Hospital, Istanbul, Turkey
| | - Mahmut Yesin
- 1 Department of Cardiology, Kosuyolu Kartal Heart Training and Research Hospital, Istanbul, Turkey
| | - Mustafa Ozan Gürsoy
- 1 Department of Cardiology, Kosuyolu Kartal Heart Training and Research Hospital, Istanbul, Turkey
| | - Sabahattin Gündüz
- 1 Department of Cardiology, Kosuyolu Kartal Heart Training and Research Hospital, Istanbul, Turkey
| | - Süleyman Karakoyun
- 1 Department of Cardiology, Kosuyolu Kartal Heart Training and Research Hospital, Istanbul, Turkey
| | - Mehmet Ali Astarcıoğlu
- 1 Department of Cardiology, Kosuyolu Kartal Heart Training and Research Hospital, Istanbul, Turkey
| | - Emrah Bayam
- 1 Department of Cardiology, Kosuyolu Kartal Heart Training and Research Hospital, Istanbul, Turkey
| | - Sinan Cerşit
- 1 Department of Cardiology, Kosuyolu Kartal Heart Training and Research Hospital, Istanbul, Turkey
| | - Mehmet Özkan
- 1 Department of Cardiology, Kosuyolu Kartal Heart Training and Research Hospital, Istanbul, Turkey.,2 Division of Health Sciences, University of Ardahan, Ardahan, Turkey
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Sekaggya C, Nalwanga D, Von Braun A, Nakijoba R, Kambugu A, Fehr J, Lamorde M, Castelnuovo B. Challenges in achieving a target international normalized ratio for deep vein thrombosis among HIV-infected patients with tuberculosis: a case series. BMC HEMATOLOGY 2016; 16:16. [PMID: 27274846 PMCID: PMC4893228 DOI: 10.1186/s12878-016-0056-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Accepted: 05/24/2016] [Indexed: 11/30/2022]
Abstract
Background Tuberculosis (TB) and HIV are among the risk factors for deep vein thrombosis (DVT). There are several challenges in the management of DVT patients with TB-HIV co-infection including drug-drug interactions and non-adherence due to pill burden. Methods HIV infected patients starting treatment for TB were identified and followed up two weekly. Cases of DVT were diagnosed with Doppler ultrasound and patients were initiated on oral anticoagulation with warfarin and followed up with repeated INR measurements and warfarin dose adjustment. Results We describe 7 cases of TB and HIV-infected patients in Uganda diagnosed with DVT and started on anticoagulation therapy. Their median age was 30 (IQR: 27–39) years and 86 % were male. All patients had co-medication with cotrimoxazole, tenofovir, lamivudine and efavirenz and some were on fluconazole. The therapeutic range of the International Normalization Ratio (INR) was difficult to attain and unpredictable with some patients being under-anticoagulated and others over-anticoagulated. The mean Time in Therapeutic Range (TTR) for patients who had all scheduled INR measurements in the first 12 weeks was 33.3 %. Only one patient among those with all the scheduled INR measurements had achieved a therapeutic INR by 2 weeks. Four out of seven (57 %) of the patients had at least one INR above the therapeutic range which required treatment interruption. None of the patients had major bleeding. Conclusion We recommend more frequent monitoring and timely dose adjustment of the INR, as well as studies on alternative strategies for the treatment of DVT in TB-HIV co-infected patients.
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Affiliation(s)
- C Sekaggya
- Infectious Diseases Institute, College of Health Sciences, Makerere University, P.O. Box 22418, Kampala, Uganda
| | - D Nalwanga
- Infectious Diseases Institute, College of Health Sciences, Makerere University, P.O. Box 22418, Kampala, Uganda
| | - A Von Braun
- Infectious Diseases Institute, College of Health Sciences, Makerere University, P.O. Box 22418, Kampala, Uganda
| | - R Nakijoba
- Infectious Diseases Institute, College of Health Sciences, Makerere University, P.O. Box 22418, Kampala, Uganda
| | - A Kambugu
- Infectious Diseases Institute, College of Health Sciences, Makerere University, P.O. Box 22418, Kampala, Uganda
| | - J Fehr
- Division of Infectious Diseases and Infection Control, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - M Lamorde
- Infectious Diseases Institute, College of Health Sciences, Makerere University, P.O. Box 22418, Kampala, Uganda
| | - B Castelnuovo
- Infectious Diseases Institute, College of Health Sciences, Makerere University, P.O. Box 22418, Kampala, Uganda
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Lip GY, Mitchell SA, Liu X, Liu LZ, Phatak H, Kachroo S, Batson S. Relative efficacy and safety of non-Vitamin K oral anticoagulants for non-valvular atrial fibrillation: Network meta-analysis comparing apixaban, dabigatran, rivaroxaban and edoxaban in three patient subgroups. Int J Cardiol 2016; 204:88-94. [DOI: 10.1016/j.ijcard.2015.11.084] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Accepted: 11/14/2015] [Indexed: 10/22/2022]
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Alonso Roca R, Figueroa Guerrero CA, Mainar de Paz V, Arribas García MP, Sánchez Perruca L, Rodríguez Barrientos R, Casado López M, Pedraza Flechas AM. Grado de control del tratamiento anticoagulante oral en los centros de Atención Primaria de la Comunidad de Madrid: estudio CHRONOS-TAO. Med Clin (Barc) 2015; 145:192-7. [DOI: 10.1016/j.medcli.2014.09.023] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2014] [Revised: 09/22/2014] [Accepted: 09/25/2014] [Indexed: 12/21/2022]
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Samadoulougou AK, Naibe DT, Mandi DG, Kabore E, Millogo GRC, Yameogo NV, Kologo JK, Tall AT, Toguyeni BJY, Zabsonre P. [Evaluation of the knowledge of patients about the management of treatment with anti-vitamin K drugs in the Service of Cardiology of Ouagadougou]. Ann Cardiol Angeiol (Paris) 2015; 64:263-267. [PMID: 26275496 DOI: 10.1016/j.ancard.2015.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2014] [Accepted: 01/04/2015] [Indexed: 06/04/2023]
Abstract
INTRODUCTION Vitamin K antagonists (VKA), the most widely prescribed oral anticoagulant therapy, represent a major public health problem by the adverse events related to their use. The aim of this study was to clarify the level of knowledge that patients have about the management of their oral anticoagulant treatment. PATIENTS AND METHODS This was a descriptive cross-sectional study performed at Yalgado Ouedraogo university Hospital, over a period of three months starting from March 1st to May 31st 2012. A questionnaire was given to patients receiving VKA treatment for at least a month. RESULTS Seventy patients were enrolled in the study of which 30 men. The median age was 49±16 years. Heart disease and venous thromboembolic disease justifying the introduction of VKA treatment were found respectively in 58.6 and 41.4% of the cases. The name of the VKA and the exact reason for the treatment were known respectively in 91.4 and 61.7% of the case. More than half of patients (68.6%) knew that the VKA makes blood more fluid. Forty-six patients (65.7%) cited INR as biological monitoring of treatment but only 28 patients (40%) were aware of INR target values. The majority of patients did not know the risks in case of overdose (72.8%) and underdosing (71.4%). Self-medication by non-steroidal anti-inflammatory drugs was reported by 18 patients (25.7%). Cabbage (74.3%) and lettuce (62.9%) were the main foods reported to be consumed moderately. CONCLUSION The knowledge of patients on the management of VKA is fragmentary and remains insufficient to ensure the effectiveness of the treatment. The creation of a therapeutic education program is then necessary.
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Affiliation(s)
- A K Samadoulougou
- Service de cardiologie, CHU Yalgado Ouédraogo, avenue du Capitaine-Thomas-Sankara, 03 BP, 702250 Ouagadougou, Burkina Faso; Unité de formation et de recherche en science de la santé, université de Ouagadougou, Ouagadougou, Burkina Faso
| | - D T Naibe
- Service de cardiologie, CHU Yalgado Ouédraogo, avenue du Capitaine-Thomas-Sankara, 03 BP, 702250 Ouagadougou, Burkina Faso.
| | - D G Mandi
- Service de cardiologie, CHU Yalgado Ouédraogo, avenue du Capitaine-Thomas-Sankara, 03 BP, 702250 Ouagadougou, Burkina Faso
| | - E Kabore
- Service de cardiologie, CHU Yalgado Ouédraogo, avenue du Capitaine-Thomas-Sankara, 03 BP, 702250 Ouagadougou, Burkina Faso
| | - G R C Millogo
- Service de cardiologie, CHU Yalgado Ouédraogo, avenue du Capitaine-Thomas-Sankara, 03 BP, 702250 Ouagadougou, Burkina Faso; Unité de formation et de recherche en science de la santé, université de Ouagadougou, Ouagadougou, Burkina Faso
| | - N V Yameogo
- Service de cardiologie, CHU Yalgado Ouédraogo, avenue du Capitaine-Thomas-Sankara, 03 BP, 702250 Ouagadougou, Burkina Faso; Unité de formation et de recherche en science de la santé, université de Ouagadougou, Ouagadougou, Burkina Faso
| | - J K Kologo
- Service de cardiologie, CHU Yalgado Ouédraogo, avenue du Capitaine-Thomas-Sankara, 03 BP, 702250 Ouagadougou, Burkina Faso
| | - A T Tall
- Service de cardiologie, CHU Yalgado Ouédraogo, avenue du Capitaine-Thomas-Sankara, 03 BP, 702250 Ouagadougou, Burkina Faso
| | - B J Y Toguyeni
- Service de cardiologie, CHU Yalgado Ouédraogo, avenue du Capitaine-Thomas-Sankara, 03 BP, 702250 Ouagadougou, Burkina Faso
| | - P Zabsonre
- Service de cardiologie, CHU Yalgado Ouédraogo, avenue du Capitaine-Thomas-Sankara, 03 BP, 702250 Ouagadougou, Burkina Faso; Unité de formation et de recherche en science de la santé, université de Ouagadougou, Ouagadougou, Burkina Faso
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Macedo AF, Bell J, McCarron C, Conroy R, Richardson J, Scowcroft A, Sunderland T, Rotheram N. Determinants of oral anticoagulation control in new warfarin patients: analysis using data from Clinical Practice Research Datalink. Thromb Res 2015; 136:250-60. [DOI: 10.1016/j.thromres.2015.06.007] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Revised: 05/18/2015] [Accepted: 06/04/2015] [Indexed: 11/16/2022]
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McNab D, McKay J, Bowie P. A before and after study of warfarin monitoring in a single region as part of the Scottish patient safety programme in primary care. Scott Med J 2015. [DOI: 10.1177/0036933015597178] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction Warfarin is an effective drug for patients at risk of thromboembolic events, but sub-optimal pharmacological management may cause significant harm. As part of the Scottish patient safety programme in primary care, one health board region aimed to determine if the international normalised ratio control for patients taking warfarin in general practice improved over the first 12 months of participation. Methods A before and after study of a multi-intervention improvement strategy was employed that combined financial incentivisation, a regional learning collaborative, clinical care bundle implementation, audit and feedback and clinical ‘safety champions’. The main patient outcome measures were: mean time in therapeutic range; proportion with good control (time in therapeutic range >60%) and excellent control (time in therapeutic range > 75%); and the proportion of very abnormal results (international normalised ratio < 1.5 or >5). Chi-square tests were used to determine statistical differences. Results In total, 49 of 55 general practices participated (89%) with 33/55 providing usable data (60%) on 1480 patients (before) and 1946 patients (after), respectively. Improvements were observed in mean time in therapeutic range ( P < 0.05) as well as in the proportion of patients with good control (time in therapeutic range > 60%, P < 0.01) and excellent control (time in therapeutic range > 75%, P = 0.06). A reduction in the proportion of very abnormal results (international normalised ratio < 1.5 or >5) was also observed ( P < 0.01), while the mean number of patient attendances reduced ( P < 0.05). Conclusions The introduction of a complex safety improvement intervention via a national patient safety programme has resulted in modest improvements in the control of warfarin monitoring in a single region. These improvements may potentially reduce the incidence of serious adverse events. The study method, interventions and findings should be of interest to primary care settings with similar warfarin management arrangements internationally.
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Affiliation(s)
- Duncan McNab
- Medical Directorate, NHS Education for Scotland, UK
- GP/Patient Safety Clinical Lead, NHS Ayrshire and Arran, UK
| | - John McKay
- Medical Directorate, NHS Education for Scotland, UK
| | - Paul Bowie
- Medical Directorate, NHS Education for Scotland, UK
- Institute of Health and Wellbeing, University of Glasgow, UK
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Rouaud A, Hanon O, Boureau AS, Chapelet GG, de Decker L. Comorbidities against quality control of VKA therapy in non-valvular atrial fibrillation: a French national cross-sectional study. PLoS One 2015; 10:e0119043. [PMID: 25789771 PMCID: PMC4366229 DOI: 10.1371/journal.pone.0119043] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2014] [Accepted: 01/09/2015] [Indexed: 01/21/2023] Open
Abstract
Background Given the prevalence of non-valvular atrial fibrillation in the geriatric population, thromboembolic prevention by means of vitamin K antagonists (VKA) is one of the most frequent daily concerns of practitioners. The effectiveness and safety of treatment with VKA correlates directly with maximizing the time in therapeutic range, with an International Normalized Ratio (INR) of 2.0-3.0. The older population concentrates many of factors known to influence INR rate, particularly concomitant medications and concurrent medical conditions, also defined as comorbidities. Objective Determine whether a high burden on comorbidities, defined by a Charlson Comorbidity Index (CCI) of 3 or greater, is associated a lower quality of INR control. Study-Design Cross-sectional study. Settings French geriatric care units nationwide. Participants 2164 patients aged 80 and over and treated with vitamin K antagonists. Measurements Comorbidities were assessed using the Charlson Comorbidity Index (CCI). The recorded data included age, sex, falls, kidney failure, hemorrhagic event, VKA treatment duration, and the number and type of concomitant medications. Quality of INR control, defined as time in therapeutic range (TTR), was assessed using the Rosendaal method. Results 487 patients were identified the low-quality control of INR group. On multivariate logistic regression analysis, low-quality control of INR was independently associated with a CCI ≥3 (OR = 1.487; 95% CI [1.15; 1.91]). The other variables associated with low-quality control of INR were: hemorrhagic event (OR = 3.151; 95% CI [1.64; 6.07]), hospitalization (OR = 1.614, 95% CI [1.21; 2.14]). Conclusion An elevated CCI score (≥3) was associated with low-quality control of INR in elderly patients treated with VKA. Further research is needed to corroborate this finding.
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Affiliation(s)
- Agnes Rouaud
- Department of Geriatrics, EA 1156–12, Nantes University Hospital, Nantes, France
- * E-mail:
| | - Olivier Hanon
- Department of Geriatrics, Broca Hospital, Public Hospital of Paris, Paris, France
| | - Anne-Sophie Boureau
- Department of Geriatrics, EA 1156–12, Nantes University Hospital, Nantes, France
| | | | - Laure de Decker
- Department of Geriatrics, EA 1156–12, Nantes University Hospital, Nantes, France
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Samadoulougou A, Temoua Naibe D, Mandi G, Yameogo RA, Kabore E, Millogo G, Yameogo NV, Kologo JK, Thiam Tall A, Toguyeni BJY, Zabsonre P. [Evaluation of the level of knowledge of patients on treatment with vitamin K antagonists in Ouagadougou cardiology department]. Pan Afr Med J 2014; 19:286. [PMID: 25870741 PMCID: PMC4391894 DOI: 10.11604/pamj.2014.19.286.5411] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Accepted: 10/31/2014] [Indexed: 11/28/2022] Open
Abstract
Introduction Les antivitamines K (AVK), traitement anticoagulant oral le plus largement prescrit, posent un réel problème de santé publique du fait de leur risque iatrogène. L'objectif de cette étude était de préciser le niveau de connaissance des patients sur la gestion de leur traitement par les AVK. Méthodes Il s'est agi d'une enquête transversale descriptive réalisée au CHU-Yalgado Ouédraogo, sur une période de 03 mois : du 1er mars au 31 mai 2012. Un questionnaire a été administré aux patients bénéficiant d'un traitement AVK depuis au moins un mois. Résultats Soixante-dix patients ont été inclus dans l'étude dont 30 hommes. L'âge moyen était de 49 ans ± 16 ans. Les cardiopathies et la maladie thromboembolique veineuse justifiant l'institution du traitement AVK étaient retrouvées respectivement dans 58,6% et 41,4% des cas. Le nom de l'AVK et la raison exacte du traitement étaient connus respectivement dans 91,4% et 67,1% des cas. Plus de la moitié des patients (68,6%) savaient que les AVK rendaient le sang plus fluide. Quarante-six patients (65,7%) citaient l'INR comme examen biologique de surveillance du traitement et seulement 28 patients (40%) connaissaient les valeurs cibles. La majorité des patients ne connaissait pas les risques encourus en cas de surdosage (72,8%) et de sous-dosage (71,4%). Une automédication par anti-inflammatoire non stéroïdien était signalée par 18 patients (25,7%). Les choux (74,3%) et la laitue (62,9%), aliments à consommer avec modération, étaient les plus cités. Conclusion Les connaissances des patients sur la gestion des AVK étaient fragmentaires et insuffisantes pour assurer la sécurité et l'efficacité du traitement. La création d'un programme d'éducation thérapeutique sur les AVK s'avère alors nécessaire.
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Affiliation(s)
- André Samadoulougou
- Service de Cardiologie du CHU Yalgado Ouedraogo, Ouagadougou, Burkina Faso ; Unité de Formation et de Recherche en Science de la Santé, Université de Ouagadougou, Ouagadougou, Burkina Faso
| | | | - Germain Mandi
- Service de Cardiologie du CHU Yalgado Ouedraogo, Ouagadougou, Burkina Faso
| | | | - Elisé Kabore
- Service de Cardiologie du CHU Yalgado Ouedraogo, Ouagadougou, Burkina Faso
| | - Georges Millogo
- Service de Cardiologie du CHU Yalgado Ouedraogo, Ouagadougou, Burkina Faso ; Unité de Formation et de Recherche en Science de la Santé, Université de Ouagadougou, Ouagadougou, Burkina Faso
| | - Nobila Valentin Yameogo
- Service de Cardiologie du CHU Yalgado Ouedraogo, Ouagadougou, Burkina Faso ; Unité de Formation et de Recherche en Science de la Santé, Université de Ouagadougou, Ouagadougou, Burkina Faso
| | | | - Anna Thiam Tall
- Service de Cardiologie du CHU Yalgado Ouedraogo, Ouagadougou, Burkina Faso
| | | | - Patrice Zabsonre
- Service de Cardiologie du CHU Yalgado Ouedraogo, Ouagadougou, Burkina Faso ; Unité de Formation et de Recherche en Science de la Santé, Université de Ouagadougou, Ouagadougou, Burkina Faso
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Nantha YS. Anticoagulation Management of Atrial Fibrillation: The Relationship of Prevailing Adherence to a Dose Protocol and Recall Schedule on TTR in Primary Care. Health Serv Res Manag Epidemiol 2014; 1:2333392814552524. [PMID: 28462246 PMCID: PMC5278818 DOI: 10.1177/2333392814552524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective: To investigate the prevailing level of adherence to a dosing algorithm and a recall schedule and its relationship with the time in therapeutic range (TTR) among patients with atrial fibrillation. Methods: The study was carried out at a regional primary care clinic in Malaysia. Patients on anticoagulation therapy aged older than 18 years were included in the study. The participants have received continuation of their anticoagulation therapy at the primary care clinic for at least 6 months to 1 year after being discharged from a tertiary center. Correlation and multiple regression studies were performed to determine the significance of the predictors of TTR. Results: A majority (217) of patients with atrial fibrillation received anticoagulation therapy at the clinic followed by patients with mitral valve replacement and aortic valve replacement. The mean TTR for patients with atrial fibrillation was 57.6%. General practitioners (GPs) adhered to 75.5% of the dose protocol but fared poorly in adhering to the recall schedule (36.2%). The concordance to the dose algorithm and recall schedule were significantly related to TTR. Multiple regression analysis proved that the concordance to the dose algorithm and recall schedule were important predictors of the level of TTR in patients with atrial fibrillation. Discussion: The study provides preliminary evidence on the relationship between a validated dose algorithm that is integrated with a recall schedule in the control of TTR in patients with atrial fibrillation on anticoagulation treatment. A larger multicenter study is needed to confirm the results of this finding.
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Cotté FE, Benhaddi H, Duprat-Lomon I, Doble A, Marchant N, Letierce A, Huguet M. Vitamin K Antagonist Treatment in Patients With Atrial Fibrillation and Time in Therapeutic Range in Four European Countries. Clin Ther 2014; 36:1160-8. [DOI: 10.1016/j.clinthera.2014.07.016] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Revised: 07/11/2014] [Accepted: 07/23/2014] [Indexed: 11/27/2022]
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Havasi K. Efficacy and safety of apixaban compared with warfarin regarding time within the therapeutic range. Orv Hetil 2014; 155:177-81. [DOI: 10.1556/oh.2014.29792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Prevention of thromboembolism by lifelong anticoagulation is an important therapeutic goal in patients with atrial fibrillation according to recent guidelines. Major drawback of vitamin K antagonists are their narrow therapeutic range and interactions with other drugs and food. These have significant impact on the pharmacokinetics and pharmacodynamics requiring regular measurements of the international normalized ratio. Efficiency of the anticoagulant therapy depends considerably on time within the therapeutic range of prothrombin international normalized ratio. Time within the therapeutic range represents the percentage of time within the required range of prothrombin international normalized ratio. Prothrombin international normalized ratio outside the therapeutic range increases the risk of thromboembolism or bleeding according to whether it falls below or above the range. New oral anticoagulants do not require routine monitoring of anticoagulation. Their efficacy and safety are shown to be at least as good as or better than those of warfarin. In patients with nonvalvular atrial fibrillation ARISTOTLE study revealed that antithrombotic effect of apixaban compared with warfarin is better and with lower bleeding risk irrespective of the quality of prothrombin international normalized ratio control. Orv. Hetil., 2014, 155(5), 177–181.
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Affiliation(s)
- Kálmán Havasi
- Szegedi Tudományegyetem, Általános Orvostudományi Kar II. Belgyógyászati Klinika és Kardiológiai Központ Szeged Korányi fasor 6. 6720
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Nielsen PB, Lundbye-Christensen S, Rasmussen LH, Larsen TB. Improvement of anticoagulant treatment using a dynamic decision support algorithm: a Danish Cohort study. Thromb Res 2014; 133:375-9. [PMID: 24444650 DOI: 10.1016/j.thromres.2013.12.042] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2013] [Revised: 12/21/2013] [Accepted: 12/30/2013] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Warfarin is the most widely prescribed vitamin K antagonist and in the United States and Europe more than 10 million people are currently in long-term oral anticoagulant treatment. This study aims to retrospectively validate a dynamic statistical model providing dosage suggestions to patients in warfarin treatment. MATERIALS AND METHODS The model was validated on a cohort of 553 patients with a mean TTR of 83%. Patients in the cohort were self-monitoring and managed by a highly specialised anticoagulation clinic. The predictive model essentially consists of three parts handling INR history, warfarin dosage and biological noise, which allows for prediction of future INR values and optimal warfarin dose to stay on INR target. Further, the model is based on parameters initially being set to population values and gradually individualised during monitoring of patients. PRIMARY OUTCOME Time in therapeutic range was used as surrogate quality measure of the treatment, and model-suggested dosage of warfarin was used to assess the accuracy of the model performance. RESULTS The accuracy of the model predictions measured as median absolute error was 0.53 mg/day (interquartile range from 0.25 to 1.0). The model performance was evaluated by the difference between observed and predicted warfarin intake in the preceding week of an INR measurement. In more than 70% of the cases where INR measurements were outside the therapeutic range, the model suggested a more reasonable dose than the observed intake. CONCLUSION Applying the proposed dosing algorithm can potentially further increase the time in INR target range beyond 83%.
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Affiliation(s)
| | | | | | - Torben Bjerregaard Larsen
- Thrombosis Research Unit, Aalborg University, Aalborg, Denmark; Department of Cardiology, Aalborg AF study group, Aalborg University Hospital, Aalborg, Denmark
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Use of Vitamin K Antagonist Therapy in Geriatrics: A French National Survey from the French Society of Geriatrics and Gerontology (SFGG). Drugs Aging 2013; 30:1019-28. [DOI: 10.1007/s40266-013-0127-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Qualls LG, Greiner MA, Eapen ZJ, Fonarow GC, Mills RM, Klaskala W, Hernandez AF, Curtis LH. Postdischarge international normalized ratio testing and long-term clinical outcomes of patients with heart failure receiving warfarin: findings from the ADHERE registry linked to Medicare claims. Clin Cardiol 2013; 36:757-65. [PMID: 24114926 DOI: 10.1002/clc.22206] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2013] [Revised: 08/15/2013] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Effective warfarin thromboprophylaxis requires maintaining anticoagulation within the recommended international normalized ratio (INR) range. INR testing rates and associations between testing and outcomes are not well understood. HYPOTHESIS INR testing rates after hospitalization for acute decompensated heart failure are suboptimal, and testing is associated with lower risks of mortality and adverse clinical events. METHODS We conducted a retrospective cohort study of patients who were long-term warfarin users and were hospitalized for heart failure, had a medical history of atrial fibrillation or valvular heart disease, and were enrolled in fee-for-service Medicare. INR testing was defined as ≥1 outpatient INR test within 45 days after discharge. Using Cox proportional hazards models, we examined associations between testing and all-cause mortality, all-cause readmission, and adverse clinical events at 1 year. RESULTS Among 8558 patients, 7722 (90.2%) were tested. After 1 year, tested patients had lower all-cause mortality (23.5% vs 32.6%; P < 0.001) and fewer myocardial infarctions (2.0% vs 3.3%; P = 0.02). These differences remained significant after multivariable adjustment with hazard ratios of 0.72 (95% confidence interval [CI]: 0.63-0.84; P < 0.001) and 0.58 (95% CI: 0.41-0.83; P = 0.003), respectively. Differences in all-cause readmission, thromboembolic events, ischemic stroke, and bleeding events were not statistically significant. CONCLUSIONS Postdischarge outpatient INR testing in patients with heart failure complicated by atrial fibrillation or valvular heart disease was high. INR testing was associated with improved survival and fewer myocardial infarctions at 1 year but was not independently associated with other adverse clinical events.
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Affiliation(s)
- Laura G Qualls
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
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Ewen S, Rettig-Ewen V, Mahfoud F, Böhm M, Laufs U. Drug adherence in patients taking oral anticoagulation therapy. Clin Res Cardiol 2013; 103:173-82. [PMID: 23999974 DOI: 10.1007/s00392-013-0616-8] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2013] [Accepted: 08/27/2013] [Indexed: 10/26/2022]
Abstract
Oral anticoagulation has proven to reduce mortality and morbidity of thromboembolic events. One of the most important determinants of the effectiveness and safety of anticoagulation therapy is the adherence to the prescribed therapy. Vitamin K antagonists are characterized by under-utilization, a narrow therapeutic window and multiple food and drug interactions which contribute to a variable dose-response relationship with the risk of insufficient protection and/or increased bleeding risk. The "new" direct oral anticoagulants have demonstrated equal or superior protection and reduced bleeding risks compared to warfarin and are easier to use because of fixed dosing without monitoring of anticoagulation. Controlling of adherence to the direct oral anticoagulants is difficult. Therefore, continuous and regular medication intake represents a pre-requisite for achieving optimal protection. The present review aims to give an overview about the factors that affect drug adherence in patients taking oral anticoagulation drugs and discusses strategies to improve drug adherence.
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Affiliation(s)
- Sebastian Ewen
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Kirrberger Str., Geb. 40, 66421, Homburg/Saar, Germany,
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Abstract
Anticoagulation is an effective therapeutic means of reducing thrombotic risk in patients with various conditions, including atrial fibrillation, mechanical heart valves, and major surgery. By its nature, anticoagulation increases the risk of bleeding; this risk is particularly high during transitions of care. Established anticoagulants are not ideal, due to requirements for parenteral administration, narrow therapeutic indices, and/or a need for frequent therapeutic monitoring. The development of effective oral anticoagulants that are administered as a fixed dose, have low potential for drug-drug and drug-food interactions, do not require regular anticoagulation monitoring, and are suitable for both inpatient and outpatient use is to be welcomed. Three new oral anticoagulants, the direct thrombin inhibitor, dabigatran etexilate, and the factor Xa inhibitors, rivaroxaban and apixaban, have been approved in the US for reducing the risk of stroke and systemic embolism in patients with nonvalvular atrial fibrillation; rivaroxaban is also approved for prophylaxis and treatment of deep vein thrombosis, which may lead to pulmonary embolism in patients undergoing knee or hip replacement surgery. This review examines current options for anticoagulant therapy, with a focus on maintaining efficacy and safety during transitions of care. The characteristics of dabigatran etexilate, rivaroxaban, and apixaban are discussed in the context of traditional anticoagulant therapy.
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Affiliation(s)
- Franklin Michota
- Department of Hospital Medicine, Cleveland Clinic, Cleveland, OH, USA
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Risk versus Benefit of Non-Vitamin K Dependent Anticoagulants Compared to Warfarin for the Management of Atrial Fibrillation in the Elderly. Drugs Aging 2013; 30:513-25. [DOI: 10.1007/s40266-013-0075-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Nutescu EA, Bautista A, Gao W, Galanter WL, Schumock GT, Mody SH, Bookhart BK, Lambert BL. Warfarin anticoagulation after total hip or total knee replacement: Clinical and resource-utilization outcomes in a university-based antithrombosis clinic. Am J Health Syst Pharm 2013; 70:423-30. [DOI: 10.2146/ajhp120341] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Affiliation(s)
- Edith A. Nutescu
- Department of Pharmacy Practice and Center for Pharmacoeconomic Research, College of Pharmacy, University of Illinois at Chicago, Chicago
| | - Adriana Bautista
- Department of Pharmacy Practice and Center for Pharmacoeconomic Research, College of Pharmacy, University of Illinois at Chicago, Chicago
| | - Weihua Gao
- Center for Clinical and Translational Science, University of Illinois at Chicago, Chicago
| | - William L. Galanter
- Department of Medicine, College of Medicine; Clinical Assistant Professor of Pharmacy Practice, Department of Pharmacy Practice, College of Pharmacy, University of Illinois at Chicago, Chicago
| | - Glen T. Schumock
- Department of Pharmacy Practice and Center for Pharmacoeconomic Research, College of Pharmacy, University of Illinois at Chicago, Chicago
| | | | - Brahim K. Bookhart
- Health Economics and Outcomes Research, Janssen Scientific Affairs, LLC, Raritan, NJ
| | - Bruce L. Lambert
- Department of Pharmacy Administration and Center for Education and Research on Therapeutics, University of Illinois at Chicago
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Basileo M, Micheluzzi C, Minozzi M, Lazzaroni L, Iorio A. Clinical validation of a new algorithm for computerized dosing of vitamin K antagonist therapy: a retrospective simulation study. Intern Emerg Med 2013; 8:55-63. [PMID: 21468696 DOI: 10.1007/s11739-011-0581-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2010] [Accepted: 03/17/2011] [Indexed: 10/18/2022]
Abstract
The number of patients on oral anticoagulant therapy has increased in recent years, and this trend is expected to continue. The increased workload for physicians has led to the development of computerized systems to make organizational workflow more efficient. These programs may include algorithms to propose a weekly dosage and timing for the following visit. Before introducing a new algorithm in clinical practice, its safety and efficacy must be validated. We undertook a retrospective simulation study to test a new algorithm for the TAOnet system. The main outcome was the percentage of concordant and discordant proposals between manual- and algorithm-based prescriptions. Pairs of computerized and physician prescriptions were assessed. They were categorized as 0.1-5, 5.1-10 and >10% if the dose was different, and assigned as "algorithm better" or "manual better" dependent upon the subsequent international normalized ratio value. In 61.0% of cases, the manual and computerized weekly dosage assignments were identical; in 15.3% of cases, the difference was between 0.1 and 5%; in 14.7 of cases, it was between 5.1 and 10%; and in 9.0% of cases, it was >10%. The algorithm did better in 43.9% of discordant pairs, generally due to less frequent under-dosing. In conclusion, the new algorithm proved to consistently overlap with the manual method. The algorithm is useful but must be tested in a multi-center, prospective, interventional study.
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Affiliation(s)
- Michela Basileo
- Department of Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy
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Graham MR, Fish K, Schaefer RS, Galyean R, Hardinger KL. Evaluation of a Pharmacist-Managed Anticoagulation Clinic. Hosp Pharm 2012. [DOI: 10.1310/hpj4711-848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Background Anticoagulation therapy is important in the prevention and treatment of cardioembolic events. Warfarin is frequently used but requires continual monitoring to ensure safety and efficacy. The target time in therapeutic range (TTR) is not always achieved. Objectives The objectives for this study were to determine the TTR for a pharmacist-managed anticoagulation clinic and identify reasons for sub- and supratherapeutic international normalized ratio (INR) values. Methods Medical records for subjects prescribed warfarin were reviewed. Demographic and relevant clinical information was assessed. INR measurements were extracted for subjects enrolled. The TTR was calculated, and the cause for sub- or supratherapeutic values was determined when possible. Results One hundred twenty-six subjects were included in this retrospective study. The calculated TTR was 51%. The cause for more than 65% of the sub- and supratherapeutic INR values could not be determined. One subject incurred a clot and 6 subjects suffered a bleed. No deaths occurred. Age was the only factor that correlated with a supratherapeutic INR value ( r = −0.179, P = .045). Conclusion Pharmacists in the anticoagulation clinic are effectively managing patients who are taking warfarin by frequently maintaining INR values near or within the recommended therapeutic range. Very few negative outcomes occurred during the time of study.
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Affiliation(s)
| | | | - R. Spencer Schaefer
- Anticoagulation Pharmacy Specialist, Veterans Affairs Medical Center, Kansas City, Missouri
| | - Rick Galyean
- Anticoagulation Pharmacy Specialist, Veterans Affairs Medical Center, Kansas City, Missouri
| | - Karen L. Hardinger
- University of Missouri-Kansas City School of Pharmacy, Kansas City, Missouri
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Erkens PMG, ten Cate H, Büller HR, Prins MH. Benchmark for time in therapeutic range in venous thromboembolism: a systematic review and meta-analysis. PLoS One 2012; 7:e42269. [PMID: 23049730 PMCID: PMC3458058 DOI: 10.1371/journal.pone.0042269] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2012] [Accepted: 07/02/2012] [Indexed: 01/31/2023] Open
Abstract
INTRODUCTION The percentage of time within the target INR range 2.0 to 3.0 (TTR) in patients treated with vitamin K antagonists varies considerably among efficacy-studies of novel anticoagulants. In order to properly asses the quality of anticoagulant control in upcoming cost-effectiveness studies and real life registries this systematic review reports a benchmark of TTR for different treatment durations in patients with venous thromboembolism and discusses ways to calculate TTR. METHODS Medline and Embase were searched for studies published between January 1990 and May 2012. Randomized controlled trials and cohort studies reporting the TTR in patients with objectively confirmed venous thromboembolism treated with vitamin K antagonists (VKA) were eligible. Duplicate reports, studies only reporting INR during initial treatment or with VKA treatment less than 3 months were excluded. Three authors assessed trials for inclusion and extracted data independently. Discrepancies were resolved by discussion between the reviewers. A meta-analysis was performed by calculating a weighted mean, based on the number of participants in each included study, for each time-period in which the TTR was measured since the confirmation of the diagnosis of VTE. RESULTS Forty studies were included (26064 patients). The weighted means of TTR were 54.0% in the first month since the start of treatment, 55.6% in months 1 to 3, 60.0% in months 2 to 3, 60.0% in the months 1 to 6+ and 75.2% in months 4 to 12+. Five studies reported TTR in classes. The INR in these studies was ≥ 67% of time in therapeutic range in 72.0% of the patients. CONCLUSION Reported quality of VKA treatment is highly dependent on the time-period since the start of treatment, with TTR ranging from approximately 56% in studies including the 1(st) month to 75% in studies excluding the first 3 months.
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Affiliation(s)
- Petra M G Erkens
- Department of Family Medicine, School for Public Health and Primary Care and Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Maastricht, The Netherlands.
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Costa GLDB, Lamego RM, Colosimo EA, Valacio RA, Moreira MDCV. Identifying Potential Predictors of High-Quality Oral Anticoagulation Assessed by Time in Therapeutic International Normalized Ratio Range: A Prospective, Long-Term, Single-Center, Observational Study. Clin Ther 2012; 34:1511-20. [DOI: 10.1016/j.clinthera.2012.06.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/30/2012] [Indexed: 10/28/2022]
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Bundy DG, Marsteller JA, Wu AW, Engineer LD, Berenholtz SM, Caughey AH, Silver D, Tian J, Thompson RE, Miller MR, Lehmann CU. Electronic health record-based monitoring of primary care patients at risk of medication-related toxicity. Jt Comm J Qual Patient Saf 2012; 38:216-23. [PMID: 22649861 DOI: 10.1016/s1553-7250(12)38027-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Timely laboratory monitoring may reduce the potential harm associated with chronic medication use. A study was conducted to determine the proportion of patients receiving National Committee for Quality Assurance (NCQA)-recommended laboratory medication monitoring in a primary care setting and to assess the effect of electronic health record (EHR)-derived, paper-based, provider-specific feedback bulletins on subsequent patient receipt of medication monitoring. METHODS In a single-arm, pre-post intervention in two federally qualified community health centers in Baltimore, patients targeted were adults prescribed at least 6 months (in the preceding year) for at least one index medication (digoxin, statins, diuretics, angiotensin-converting enzyme inhibitors/ angiotensin II-receptor blockers) in a 12-month period (August 2008-July 2009). RESULTS Among the 2,013 patients for whom medication monitoring was recommended, 42% were overdue for monitoring at some point during the study. As the number of index medications the patient was prescribed increased, the likelihood of ever being overdue for monitoring decreased. Being listed on the provider-specific monitoring bulletin doubled the odds of a patient receiving recommended laboratory monitoring before the next measurement period (1-2 months). Limiting the intervention to the most overdue patients, however, mitigated its overall impact. CONCLUSIONS Recommended laboratory monitoring of chronic medications appears to be inconsistent in primary care, resulting in potential harm for individuals at risk for medication-related toxicity. EHRs may be an important component of systems designed to improve medication monitoring, but multimodal interventions will likely be needed to achieve high reliability.
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Affiliation(s)
- David G Bundy
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, USA.
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Stafford L, van Tienen EC, Bereznicki LRE, Peterson GM. The benefits of pharmacist-delivered warfarin education in the home. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2012; 20:384-9. [DOI: 10.1111/j.2042-7174.2012.00217.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2011] [Accepted: 03/27/2012] [Indexed: 11/27/2022]
Abstract
Abstract
Objectives
Good warfarin knowledge is important for optimal patient outcomes, but barriers exist to effective education and warfarin knowledge is often poor. This study aimed to explore the educational outcomes of home-based warfarin education provided by trained pharmacists.
Methods
In a prospective, non-randomised, controlled cohort trial, patients received either usual community-based post-discharge care or a post-discharge warfarin management service, including warfarin education by trained pharmacists during two or three home visits. Patients’ warfarin knowledge was assessed at 8 and 90 days post-discharge using the Oral Anticoagulation Knowledge test.
Key findings
One hundred and thirty-nine patients were recruited into the usual care group between November 2008 and August 2009, and 129 into the intervention group between May and December 2009. Pharmacist-delivered warfarin education was associated with a significant difference between the intervention patients’ baseline and day 8 mean warfarin knowledge scores of 64.5% (95% confidence interval (CI) 61.0–68.5%) and 78.0% (95% CI 74.5–81.5%; P < 0.001), respectively. The intervention patients also scored significantly higher than the usual care patients at day 8 (65.0%, 95% CI 61.5–68.0%; P < 0.001), but not at day 90.
Conclusions
Use of an existing healthcare framework overcame several systemic barriers by facilitating warfarin education in patients’ homes. While the intervention was associated with better short-term warfarin knowledge, follow-up may be required to optimise its benefits. Widespread implementation of home-based warfarin education by pharmacists has the potential to contribute significantly to improved outcomes from warfarin therapy.
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Affiliation(s)
- Leanne Stafford
- Unit for Medication Outcomes Research and Education (UMORE), University of Tasmania, Hobart, Tasmania, Australia
| | - Ella C van Tienen
- Unit for Medication Outcomes Research and Education (UMORE), University of Tasmania, Hobart, Tasmania, Australia
| | - Luke R E Bereznicki
- Unit for Medication Outcomes Research and Education (UMORE), University of Tasmania, Hobart, Tasmania, Australia
| | - Gregory M Peterson
- Unit for Medication Outcomes Research and Education (UMORE), University of Tasmania, Hobart, Tasmania, Australia
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Bauman ME, Mack G, Bruce AK, Bauman ML, Nolan K, Massicotte MP. Natural Health Product Utilization in Warfarinized Children; Prevalence and Knowledge. J Pharm Technol 2012. [DOI: 10.1177/875512251202800303] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background:The need for long-term thromboprophylaxis in children using warfarin therapy is increasing. Natural health products (NHPs) are administered to children by parents who perceive them to be useful and acceptable adjuncts or alternatives to conventional therapies. Interactions of NHPs with prescribed therapies may result in serious adverse events. NHP usage is underevaluated in children and there are no studies evaluating NHP usage in warfarinized children.Objectives:To explore NHP use in warfarinized children and their siblings to determine the prevalence, varieties, and reasons for NHP usage, as well as the potential effect on warfarinization (eg, time in therapeutic range [TTR]).Methods:This is a 3-phase cross-sectional cohort study that includes the (1) prevalence (2) NHP education and knowledge assessment, and (3) the follow-up NHP utilization phase.Results:Forty-six percent of warfarinized children consumed NHPs, with time in therapeutic range of 74%. The mean score for baseline knowledge of NHPs and warfarin following the education phase was 67%. Follow-up NHP use was 30%, and increased consistency of utilization with TTR was 83% (p < 0.05), consistent with education provided.Conclusions:The consistent prevalence rates over time of NHP usage in warfarinized children indicate the need for future studies. Education remains vital to combat the potential risks of NHP-warfarin interaction, encouraging patient disclosure and consistency.
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Affiliation(s)
- Mary E Bauman
- MARY E BAUMAN MN NP, Nurse Practitioner, Pediatric Cardiology, Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada
| | - Gordon Mack
- GORDON MACK MD, Fellow, Stollery Children's Hospital
| | - Aisha K Bruce
- AISHA K BRUCE MD FRCPC, Staff Physician, Stollery Children's Hospital
| | - Michelle L Bauman
- MICHELLE L BAUMAN BScN, Research Student, Stollery Children's Hospital
| | - Kyle Nolan
- KYLE NOLAN BA, Research Student, Stollery Children's Hospital
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