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Kow CS, Sunter W, Bain A, Zaidi STR, Hasan SS. Management of Outpatient Warfarin Therapy amid COVID-19 Pandemic: A Practical Guide. Am J Cardiovasc Drugs 2020. [PMID: 32458370 DOI: 10.1007/s40256-020-00415-z3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/13/2023]
Abstract
Many healthcare resources have been and continue to be allocated to the management of patients with COVID-19. Therefore, the ongoing care of patients receiving oral anticoagulation with warfarin is likely to be compromised amid this unprecedented crisis. This article discusses a stepwise algorithm for the management of outpatient warfarin therapy. Alternative management strategies are presented and discussed, including alternative pharmacological therapy options and self-monitoring. Our algorithm aims to help clinicians safely optimize the treatment of patients requiring anticoagulation therapy in the context of the global response to the current pandemic.
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Affiliation(s)
- Chia Siang Kow
- School of Postgraduate Studies, International Medical University, Kuala Lumpur, Malaysia
| | - Wendy Sunter
- Anticoagulant Services, Calderdale and Huddersfield NHS Foundation Trust, Huddersfield, UK
| | - Amie Bain
- Department of Pharmacy, University of Huddersfield, Huddersfield, UK
- Department of Pharmacy, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Syed Tabish Razi Zaidi
- School of Healthcare, University of Leeds, Leeds, UK
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
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Kow CS, Sunter W, Bain A, Zaidi STR, Hasan SS. Management of Outpatient Warfarin Therapy amid COVID-19 Pandemic: A Practical Guide. Am J Cardiovasc Drugs 2020; 20:301-309. [PMID: 32458370 PMCID: PMC7247959 DOI: 10.1007/s40256-020-00415-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Many healthcare resources have been and continue to be allocated to the management of patients with COVID-19. Therefore, the ongoing care of patients receiving oral anticoagulation with warfarin is likely to be compromised amid this unprecedented crisis. This article discusses a stepwise algorithm for the management of outpatient warfarin therapy. Alternative management strategies are presented and discussed, including alternative pharmacological therapy options and self-monitoring. Our algorithm aims to help clinicians safely optimize the treatment of patients requiring anticoagulation therapy in the context of the global response to the current pandemic.
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Menéndez-Jándula B, García-Erce JA, Zazo C, Larrad-Mur L. Long-term effectiveness and safety of self-management of oral anticoagulants in real-world settings. BMC Cardiovasc Disord 2019; 19:186. [PMID: 31375070 PMCID: PMC6679483 DOI: 10.1186/s12872-019-1168-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 07/23/2019] [Indexed: 02/02/2023] Open
Abstract
Background The patient self-management (PSM) is an effective approach for controlling the international normalized ratio, INR, within the therapeutic range. Nevertheless, most of the literature derives from randomized clinical trials, and no from routine clinical practice. The main objective of the present study was to evaluate long-term effectiveness and safety of PSM of oral anticoagulants (OACs) in real-world settings. Methods This prospective cohort study involved 808 patients who were trained for PSM between July 2009 and March 2012, and followed-up for a maximum observational period of 5 years. The follow-up consisted of a visit to the physician every 6 months. All patients used the same type of portable coagulometer, able to store digitally up to 100 INR measurements. Effectiveness outcomes included the percentage of patients within the therapeutic range, the time within therapeutic range (TTR), and the evolution of the TTR over 365 days of follow-up. Long-term safety profile of PSM included the incidence of all-cause deaths and complications (thromboembolic or hemorrhagic) reported between July 2009 and June 2014, and the time to event. Results The median follow-up was 3.3 years. The percentage of patients within therapeutic INR target range was 67.5%. The median TTR was 71.5%. The TTR increased over the follow-up period, either overall and regarding target INR. All-cause mortality was 2.4 per 100 patient-years (59 cases). The thromboembolic event rate was 0.9 per 100 patient-years (24 cases). The rate of major hemorrhages was 0.45 per 100 patient-years. Patients who drop out the PSM to perform the conventional management had greater rates of complications: 2.4, 1.8, and 3.4 per 100 patient-years for thromboembolic complications, major hemorrhagic events, and mortality, respectively. Conclusions The PSM of OACs is effective for maintaining patients within the INR therapeutic range for a long period of time in routine clinical practice. Results of the present study suggest that its effectiveness is at least comparable to the conventional management. Moreover, it seems safe in real-world settings, by preventing all-cause mortality, and thromboembolic and major hemorrhagic complications. Trial registration This study was not a trial, thus registration was not required.
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Brasen CL, Madsen JS, Parkner T, Brandslund I. Home Management of Warfarin Treatment Through a Real-Time Supervised Telemedicine Solution: A Randomized Controlled Trial. Telemed J E Health 2018; 25:109-115. [PMID: 29877778 DOI: 10.1089/tmj.2017.0260] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Many patients are undergoing oral anticoagulation treatment with vitamin K antagonists, which necessitates measuring international normalized ratio (INR) several times each month. INTRODUCTION Patients can learn to measure their INR at home and choose their own dose for the next period with potential gains in treatment quality and reduced healthcare expenses. This is, however, connected to the potential problem of losing tight external control of the patient treatment. MATERIALS AND METHODS We performed a randomized controlled trial using the telemedicine software CSO/AC together with the INR point-of-care-test CoaguChek XS for 10 months to investigate the use of criteria-driven healthcare interactions. A total of 87 patients were divided into two groups. The patient self-management (PSM) group was surveilled using the criteria INR <1.8, INR >4.5, change in warfarin/week >1.25 mg, missing INR or dosage. The patient self-testing (PST) group was handled as routine care. RESULTS A total of 84 patients were followed for 10 months. No differences were seen in average INR or fraction of INR in therapeutic range (2-3) in the two groups or the start compared with the end. The PST group was handled using 4.2 interactions per month whereas the PSM group used 1.1 interactions per month. No adverse effects of PSM were observed. DISCUSSION Using criteria-driven interactions enabled a considerable reduction in interactions per month. The two groups were comparable in terms of treatment effect and safety. CONCLUSIONS Using criteria to guide PSM interactions maintains good treatment effect while reducing healthcare expenses.
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Affiliation(s)
- Claus L Brasen
- 1 Department of Biochemistry and Immunology, Lillebaelt Hospital, Vejle, Denmark.,2 Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Jonna S Madsen
- 1 Department of Biochemistry and Immunology, Lillebaelt Hospital, Vejle, Denmark.,2 Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Tina Parkner
- 1 Department of Biochemistry and Immunology, Lillebaelt Hospital, Vejle, Denmark
| | - Ivan Brandslund
- 1 Department of Biochemistry and Immunology, Lillebaelt Hospital, Vejle, Denmark.,2 Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark
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Point-of-care testing INR: an overview. ACTA ACUST UNITED AC 2017; 55:800-805. [DOI: 10.1515/cclm-2016-0381] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2016] [Accepted: 09/15/2016] [Indexed: 01/17/2023]
Abstract
Abstract
Oral anticoagulant therapies with the anti-vitamin K drugs (AVK), warfarin, acenocoumarol and phenprocoumon, are employed in primary and secondary anti-thrombotic prophylaxis in patients with venous thromboembolism, atrial fibrillation and cardiac mechanical valves. However, a monitoring test such as the International Normalized Ratio (INR) is required. The periodic monitoring of this therapy entails discomfort for the patients. Telemedicine and telecare can provide significant aid in the management of this therapy allowing patients to perform the test at home or anywhere else with a portable device, i.e. point-of-care testing (POCT), and to send the result to a thrombosis (TC) via web. Patients can receive dose adjustment sent back by the TC. The effectiveness of this type of management is equal or superior to the traditional AVK monitoring in terms of hemorrhagic and thrombotic events. Analysis of the costs with a horizon of 10 years reveals that both self-testing and self-management are cost-effective. The aim of this overview is to describe the pros and cons of the use of POCT as an alternative in the monitoring of AVK. In particular, description of the POCT, decentralization, quality of the therapy, safety and costs will be examined.
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Heneghan CJ, Spencer EA, Mahtani KR. Cochrane corner: self-monitoring and self-management of oral anticoagulation. Heart 2017; 103:895-896. [PMID: 28183792 DOI: 10.1136/heartjnl-2015-309123] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Carl J Heneghan
- Nuffield Department of Primary Care Health Sciences, Centre for Evidence-Based Medicine, University of Oxford, Oxford, UK
| | | | - Kamal R Mahtani
- Nuffield Department of Primary Care Health Sciences, Centre for Evidence-Based Medicine, University of Oxford, Oxford, UK
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Kennedy M. Patients who self-monitor or self-manage can improve the quality of their oral anticoagulation therapy. Evid Based Nurs 2017; 20:17. [PMID: 27888189 DOI: 10.1136/eb-2016-102510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
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Tompson A, Heneghan C, Sutton S, Fitzmaurice D, Ward A. Impact of self-funding on patient experience of oral anticoagulation self-monitoring: a qualitative study. BMJ Open 2016; 6:e013123. [PMID: 28011812 PMCID: PMC5223672 DOI: 10.1136/bmjopen-2016-013123] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To explore the impact self-funding has on patient experience of oral anticoagulation therapy self-monitoring. DESIGN Semistructured, qualitative interviews were conducted. Transcripts were analysed thematically using constant comparison. SETTING England. PARTICIPANTS Interviewees were participants of the Cohort Study of Anticoagulation Self-Monitoring (CASM). Cohort members were recruited as they bought a monitor from the major manufacturer in the UK. A purposive sample was invited to be interviewed on completion of the 12-month cohort follow-up. DATA Patient narratives on their experiences of self-monitoring their oral anticoagulation therapy in non-trial conditions. RESULTS 26 interviews were completed. Interviewees viewed purchasing the monitoring device as a long-term commitment balancing the limitations of clinic-based monitoring against the cost. They were unable to try out the monitor prior to purchase and therefore had to be confident in their own ability to use it. The variable provision of self-monitoring equipment caused resentment, and interviewees were uncomfortable negotiating with healthcare professionals. High test strip usage while learning how to use the monitor caused anxiety that was exacerbated by worries about their cost. However, self-funding did mean that interviewees felt a sense of ownership and were determined to persevere to overcome problems. CONCLUSIONS Self-funding has negative implications in terms of equity of access; however, the money invested acts as a barrier to discontinuation. If oral anticoagulation therapy self-monitoring devices and consumables were provided free of charge in routine care, the training and support available in England may need to be reviewed to prevent discontinuation rates rising to those observed in clinical trials.
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Affiliation(s)
- Alice Tompson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Carl Heneghan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Stephen Sutton
- Institute of Public Health, University of Cambridge, Cambridge, UK
| | - David Fitzmaurice
- Primary Care Clinical Sciences, University of Birmingham, Birmingham, UK
| | - Alison Ward
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Schaefer C, Wuillemin WA, Kessels A, Jacobson A, Nagler M. Predictors of anticoagulation quality in 15 834 patients performing patient self-management of oral anticoagulation with vitamin K antagonists in real-life practice: a survey of the International Self-Monitoring Association of Orally Anticoagulated Patients. Br J Haematol 2016; 175:677-685. [PMID: 27468696 DOI: 10.1111/bjh.14273] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Accepted: 06/17/2016] [Indexed: 12/19/2022]
Abstract
Although patient self-management (PSM) of oral anticoagulation with vitamin K antagonists is recommended for patients requiring long-term anticoagulation, important aspects are still unclear. Using data from a large international survey (n = 15 834; median age 72 years; 30·1% female), we studied predictors of poor anticoagulation control (percentage of International Normalized Ratio values within therapeutic range below 75%) and developed a simple prediction model. The following variables were identified as risk factors for poor anticoagulation control and included in the final model: higher intensity of therapeutic range (odds ratio [OR] on every level 1·9; 95% confidence interval [CI] 1·8-2·0), long intervals between measurements (>14 d; 1·5; 95% CI 1·3-1·7), female sex (OR 1·3; 95% CI 1·2-1·4), and management other than PSM (OR 1·4; 95% CI 1·2-1·6). At a threshold of 0·2 (at least one variable present), the model predicted poor anticoagulation control with a sensitivity of 85·3% (95% CI: 84·0, 86·4) and a specificity of 28·5% (27·6, 29·5). The area under the receiver operated characteristic curve was 0·65. Using the proposed prediction model, physicians will be able to identify patients with a low chance of performing well, considering additional training, regular follow-up, or adjustment of therapeutic ranges.
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Affiliation(s)
- Christian Schaefer
- International Self-Montioring Association of Oral Anticoagulated Patients (ISMAAP), Geneva, Switzerland
| | - Walter A Wuillemin
- Division of Haematology and Central Haematology Laboratory, Luzerner Kantonsspital, University of Bern, Bern, Switzerland.,University of Bern, Bern, Switzerland
| | - Alfons Kessels
- Department of Anaesthesiology and Pain Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Alan Jacobson
- Department of Internal Medicine, School of Medicine, Loma Linda University, Loma Linda, CA, USA
| | - Michael Nagler
- University Clinic of Haematology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.,Department of Clinical Research, University of Bern, Bern, Switzerland
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Stroke detection and prevention in atrial fibrillation. Br J Gen Pract 2015; 65:332-3. [PMID: 26120105 DOI: 10.3399/bjgp15x685513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
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Supporting patients to self-monitor their oral anticoagulation therapy: recommendations based on a qualitative study of patients' experiences. Br J Gen Pract 2015; 65:e438-46. [PMID: 26077266 PMCID: PMC4484944 DOI: 10.3399/bjgp15x685645] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Accepted: 02/18/2015] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Clinical trials suggest that oral anticoagulation therapy (OAT) self-monitoring is safe and effective, however little is known about the patient experience of this process. There is a lack of understanding about how best to train and support patients embarking on OAT self-monitoring. AIM To collect in-depth information about patients' experiences of OAT self-monitoring outside of clinical trial conditions and to produce a set of recommendations on how best to support such patients. DESIGN AND SETTING Semi-structured qualitative interviews with patients who self-monitor and live in England. METHOD In total, 26 of the 267 (9.7%) who participated in the Cohort study of Anticoagulation Self-Monitoring (CASM) and were still self-monitoring after 12 months' follow-up were interviewed. Topics discussed included experiences of OAT self-monitoring, healthcare support, training, and decision making. Framework analysis was used. RESULTS Following initial problems using the monitoring device, interviewees described a mostly positive experience. Although less effort was expended attending monitoring appointments with health professionals, effort was required to conduct self-monitoring tests and to interpret and act on the results. Desire to self-manage was variable, especially when dosing advice systems worked promptly and reliably. Interviewees overcame patchy healthcare system knowledge and support of self-monitoring by educating themselves. Family and friends provided support with learning to use the monitor and managing OAT dosage adjustments. CONCLUSION Better, more-consistent training and health-service support would have alleviated a number of problems encountered by these patients who were self-monitoring. This training and support will become even more important if self-monitoring becomes more accessible to the general population of people on OAT.
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