Evaluation of Warfarin Anticoagulation at University of Gondar Comprehensive Specialized Hospital, North-West Ethiopia

Comparison of anticoagulation control and outcomes between usual medical care and pharmacist-led anticoagulation service in ambulatory patients taking warfarin at tertiary hospital in Ethiopia: a quasi-experimental study

BACKGROUND

We aimed to compare anticoagulation control and outcomes between usual medical care (UMC) and pharmacist-led anticoagulation services (PLAS) in patients receiving warfarin at the Tikur Anbessa Specialized Hospital (TASH), Addis Ababa, Ethiopia.

METHODS

A quasi-experimental study was conducted, including 350 (66.7%) and 175 (33.3%) patients from the UMC and PLAS groups, respectively, from 525 patients. The time in therapeutic range (TTR) was determined using the Rosendaal method, with a TTR ≥ 65% set as the cut-off for optimal anticoagulation. The two-sample Wilcoxon rank-sum (Mann-Whitney U) test was used to compare continuous variables between groups. Categorical variables were compared between groups using Pearson's chi-square test or Fisher's exact test. Logistic regression and negative binomial regression analyses were conducted to identify the factors associated with suboptimal TTR and secondary outcomes, respectively, at the p values < 0.05, and 95% confidence interval (CI).

RESULTS

Compared with the UMC group, the patients in the PLAC group showed a significantly higher median (IQR) TTR [60.89% (43.5-74.69%) vs. 53.65% (33.92-69.14%), p < 0.001]. A significantly higher optimal TTR (≥ 65%) was achieved in the PLAC group (41.7% vs. 31.7%) than in the UMC group (p = 0.002). The odds of having a poor TTR were reduced by 43% (AOR = 0.57, 95% CI = 0.36-0.88, p = 0.01) among patients in the PLAC group compared to those in the UMC group. There were no statistically significant differences in the secondary outcomes between the groups, except for all-cause emergency visits (p = 0.003). The incidence of bleeding events decreased by 3% (IRR = 0.97, 95% CI = 0.96-0.99, p < 0.001) for every increase in INR monitoring frequency. The incidence of thromboembolic events increased by a factor of 15.13 (IRR = 15.13, 95% CI = 1.47-155.52, p = 0.02) among patients with a high-risk CHA2DS2-VASc score compared with those with a moderate score.

CONCLUSION

Patients in the PLAC group had a significantly higher median TTR than those in the UMC group did. There were no statistically significant differences in the secondary outcomes between the groups, except for fewer all-cause emergency department visits in the PLAC group.

Attainment of Target in Therapeutic Range of International Normalized Ratio and Correlates Among Patients on Warfarin Therapy at Jimma Medical Center, Jimma, Ethiopia

PURPOSE

Warfarin is effective therapy to prevent thromboembolic complications of venous thromboembolism, atrial fibrillation, and cardiac thrombus, among valvular heart diseases, including in patients treated with prostheses and/or repair. Its optimum effect is achieved when the international normalized ratio (INR) is in the target therapeutic range, but a subtherapeutic level increases risk of thromboembolism and complications. This study aimed to assess the attainment of target therapeutic range, proportion, and factors associated with subtherapeutic level of warfarin.

METHODS

A hospital-based cross-sectional study was conducted at Jimma Medical Center in Jimma, Ethiopia, from October 1, 2020 through December 30, 2021. All patients on warfarin and attending Medical Follow-Up Clinics of Jimma Medical Center during the study period were included. Data were collected using structured questionnaires and then analyzed using EpiData Manager software, version 3.1 (EpiData Association). χ2 Tests and logistic regression models were used to assess relationships among variables.

FINDINGS

Of 196 patients on warfarin, ∼60% were taking it for atrial fibrillation, followed by deep venous thrombosis, women accounted for 61.7% of patients, and mean (SD) age was 43 (7) years. Most patients (61.7%) lived in rural areas and 44.9% farmed to earn a living. Most of the study participants (51.5%) had a very low monthly income of less than USD50. Most of the patients (n = 107 [54.6%]) were advised on dietary selections while on warfarin and approximately two-thirds (n = 70 [65.4%]) were adherent to the advice. Most participants (n = 118 [60.2%]) were poorly adherent to warfarin therapy and more than two-thirds of them discontinued warfarin for financial reasons. Mean (SD) duration of warfarin therapy was 15.53 (18.92) months (range 1-90 months). Most of the respondents (n = 109 [55.6%]) had subtherapeutic INR and 21 (10.7%) were in the supratherapeutic range. Although the mean (SD) time in therapeutic range was 25.03% (24.17% [range 0-80%]), in most patients (n = 166 [84.7%]), it was <60%. Poor adherence (adjusted odds ratio = 6.13; 95% CI, 3.31-28.10), shorter duration of warfarin (<12 months; adjusted odds ratio = 0.104; 95% CI, 0.012-0.875), and presence of comorbidity (adjusted odds ratio = 0.035; 95% CI, 0.004-0.323) were significantly associated with subtherapeutic INR.

IMPLICATIONS

Attainment of therapeutic INR among patients on warfarin therapy is suboptimal. This was evidenced by a significant number of patients with low time in therapeutic range, as well as INR. Poor adherence to warfarin therapy, shorter duration since initiation of warfarin, and presence of comorbid illnesses were significantly associated with subtherapeutic INR. This can lead to complications of atrial fibrillation, including thrombus formation and subsequent cardioembolic stroke, venous thromboembolism, and others, leading to morbidity, increased mortality, and poor quality of life. Therefore, providing health education and treatment for comorbidities may improve adherence, which may also improve attainment of therapeutic INR and reduce complications and improve quality of life.

Anticoagulation Management in Patients Receiving Warfarin at Private Cardiac Centers in Addis Ababa, Ethiopia

Introduction

Anticoagulants are the cornerstone therapy for thromboembolism prevention and treatment. Warfarin is the frequently prescribed drug and remains the oral anticoagulant of choice in low- and middle-income countries, including Ethiopia. It is a narrow therapeutic index drug that needs high-quality anticoagulation monitoring with frequent international normalization ratio (INR) testing.

Objective

The study aimed to assess anticoagulation management with warfarin among adult outpatients at two selected private cardiac centers in Addis Ababa, Ethiopia.

Methods

A hospital-based retrospective study design that enrolled 374 patients receiving warfarin was employed at two private cardiac centres in Addis Ababa, Ethiopia. The time in the therapeutic range (TTR) was calculated using the Rosendaal method. The data were analyzed using Statistical Package for Social Science version 25.

Results

The mean age of the patients was 57 years, and 218 (58.3%) participants were females. Out of 3384 INR tests, 1562 (46.5%) were within the therapeutic range and the mean percentage of TTR was 47.24%. Only 25.67% of the patients spent their TTR ≥ 65%. The present study revealed that dose adjustments were required 1764 times. In non-therapeutic INR values of 1764 that required warfarin dose adjustment, 59.7% of the doses were adjusted. About 262 (70.1%) of co-prescribed medications had interaction with warfarin. Sixty-four patients (17.11%) experienced bleeding events.

Conclusion

Anticoagulation management with warfarin was suboptimal in private cardiac Addis Ababa, Ethiopia, private cardiac centers. Warfarin adjustment practice for nontherapeutic INR values was not minimal, and many patients encountered bleeding during their course of therapy.

Anticoagulation control, outcomes, and associated factors in long-term-care patients receiving warfarin in Africa: a systematic review

Background

Oral anticoagulation therapy with warfarin requires frequent monitoring level of anticoagulation by the international normalized ratio (INR). In Africa, studies that explore anticoagulation control, treatment outcomes, and associated factors are reported in various ways in long-term patients receiving warfarin therapy to generate concrete scientific evidence.

Methods

The literature search was conducted in PubMed, Cochrane Library, African Journal of Online databases, Google Scholar, and Google. An advanced search strategy was computed to retrieve relevant studies related to anticoagulation control and outcomes. Duplication, title and abstract screening, and full-text assessment were conducted in Covidence software. Study quality was assessed using the Joanna Briggs Institute Critical appraisal quality assessment tool. The systematic review is registered in PROSPERO (CRD42021260772) and performed based on the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guideline.

Results

Out of 298 identified articles, 18 articles were eligible for the final review and analysis. The mean of 39.4 ± 8.4% time in therapeutic range (TTR) (29.4 to 57.3%), 36.7 ± 11.5% TTR (range 25.2–49.7%) and 46% TTR (43.5–48.5%) was computed from studies that determined TTR by Rosendaal, direct and cross-section-of-the-files methods, respectively. In this review, the lowest percentage of TTR was 13.7%, while the highest was 57.3%. The highest percentage of patients (32.25%) who had TTR ≥ 65% was reported in Tunisia, but the lowest percentages were in Namibia (10%, TTR ≥ 65%) and Kenya (10.4%, TTR ≥ 70%). Most of the included studies (11 out of 18) used Rosendaal’s method while the direct method was employed by three studies. Generally, 10.4–32.3% of study participants achieved desired optimal anticoagulation level. Regarding secondary outcomes, 1.6–7.5% and 0.006–59% of patients experienced thromboembolic complications and bleeding events, respectively. Having chronic comorbidities, taking more than two drugs, and presence of medications that potentially interact with warfarin, and patient-related factors (patients aged < 50 years old, female gender, lower education level, smoking history) were the frequently reported predictors of poor anticoagulation therapy.

Conclusions

Oral anticoagulation control was suboptimal in patients taking warfarin as evidenced by low TTR in Africa. Therefore, there is an urgent need for further improving oral anticoagulation management services.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12959-022-00416-9.

Selected hematological abnormalities and their associated factors among asthmatic patients in Northwest Ethiopia: a cross-sectional study

Background

Asthma is a chronic inflammatory disease that affects the lungs. Variation in whole blood cell lines is caused by the progression and severity of asthma. Common hematological abnormalities encountered during asthma include eosinophilia, neutrophilia, leukocytosis, and increased erythrocyte sedimentation rate. The main aim of this study was to assess the selected hematological abnormalities and their associated factors among asthmatic patients in Northwest Ethiopia from March to May 2021.

Methodology

A hospital-based cross-sectional study was conducted on a total of 320 asthmatic patients in Northwest Ethiopia. A simple random sampling technique was employed to select study participants. A pre-tested structured questionnaire and a checklist were used to collect data. Blood samples were collected from asthmatic patients for complete blood count and erythrocyte sedimentation rate determination. Hematological profiles were analyzed by Unicel DxH 800 (Beckman Coulter, Ireland). The erythrocyte sedimentation rate was determined by using the Westergren method. The data were entered into EpiData version 3.0.4 and analyzed with a statistical package for social science version 20 software. The bi-variable and multi-variable binary logistic regression models were used to assess the factors associated with hematological abnormalities. A p value of less than 0.05 in the multivariable logistic regression analysis was considered statistically significant.

Results

The overall prevalence of neutrophilia, eosinophilia, thrombocytopenia, leukocytosis, and basophilia was 35.3%, 20%, 11.9%, 10.3%, and 4.1%, respectively. Neutrophilia was associated with a lack of physical activity (AOR = 3.25; 95% CI 1.43–7.37) and a history of taking non-asthmatic drugs within the previous three months (AOR = 2.63; 95% CI 1.22–5.65). Being admitted to the emergency department (AOR = 0.27; 95% CI 0.11–5.67) was found to be associated with eosinophilia. In addition, being admitted to the emergency department (AOR = 5.44; 95%CI: 2.6–11.3) was associated with thrombocytopenia.

Conclusion

The current study demonstrated the predominant prevalence of neutrophilia, followed by eosinophilia, among asthma patients. Therefore, hematological abnormalities should be taken into account for proper monitoring and management of asthmatic patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12890-022-02020-z.

Magnitudes of Risk Factors of Venous Thromboembolism and Quality of Anticoagulant Therapy in Ethiopia: A Systematic Review

Background

Venous thromboembolism is one of the major public health problems in the world. Though several studies were conducted to estimate common risk factors of venous thromboembolism and quality of anticoagulant therapy in Ethiopia, it is difficult to estimate the overall burdens of risk factors and quality of anticoagulant use because of the lack of a nationwide study.

Objective

To assess magnitudes of risk factors of venous thromboembolism and quality of anticoagulant therapy in Ethiopia.

Materials and Methods

Electronic searching using PubMed, EMBASE, Science Direct, Cochrane Database, Scopus, Hinari, Sci-Hub, African Journals Online Library, and Free-text Web Searches using Google Scholar was conducted from September, 15 to October 27, 2021. Each of the original studies was identified by Mesh terms and Boolean search technique using full title, various keywords and was assessed using the Joanna Briggs Institute Critical Appraisal Checklist. The data were extracted using a format prepared in Microsoft Excel and exported to STATA 14.0 for the outcome analyses.

Results

The database search delivered a total of 2118 studies. After articles were removed by duplications, titles, reading the abstract, and assessed for eligibility criteria, 12 articles were found suitable for the systematic review. Prolonged immobilization (41.30%) was the most commonly observed risk factor of venous thrombosis followed by acute infection (40.25%). The proportion of therapeutic range (INR = 2-3), sub-therapeutic range (INR <2), and supra-therapeutic range (INR >3) were 32.15%, 47.58%, and 17.62%, respectively. One hundred and thirty-eight patients (11.4%) have developed minor or major bleeding complications.

Conclusion

Prolonged immobilization and acute infection were the main risk factors for venous thromboembolism. The quality of anticoagulant therapy in Ethiopia was poor and bleeding complications were high. A strong effort is needed to improve the quality of anticoagulation and close monitoring of patients' international normalized ratio is required to improve treatment outcomes.