International Normalized Ratio values in group versus individual appointments in a pharmacist-managed anticoagulation clinic

2009 ◽  
Vol 66 (13) ◽  
pp. 1218-1223 ◽  
Author(s):  
Brooke L. Griffin ◽  
Jill S. Burkiewicz ◽  
Laura R. Peppers ◽  
Terri L. Warholak
Keyword(s):  
Group Versus ◽  
International Normalized Ratio ◽  
Anticoagulation Clinic

Effect of Stress on International Normalized Ratio during Warfarin Therapy

2002 ◽  
Vol 36 (4) ◽  
pp. 617-620 ◽  
Author(s):  
Toni L Hawk ◽  
Dawn E Havrda
Keyword(s):  
Physical Activity ◽  
Drug Interactions ◽  
Patient Compliance ◽  
Warfarin Therapy ◽  
International Normalized Ratio ◽  
Anticoagulation Clinic ◽  
Stressful Events ◽  
Stressful Event ◽  
Dietary Changes ◽  
Case Summary

OBJECTIVE: To discuss the effect of stress on the international normalized ratio (INR) when patients are taking warfarin. CASE SUMMARY: Two patients at a pharmacist-managed anticoagulation clinic who were stable with anticoagulation developed elevated INR values after a stressful event occurred. All other factors known to elevate the INR were unchanged; furthermore, the INR values returned to the prior level of control after resolution of the stressful events. DISCUSSION: Management of anticoagulation with warfarin requires the knowledge of factors that may alter an INR. Many of these factors, such as dietary changes, illnesses, drug interactions, patient compliance, and physical activity, have been described. In spite of this understanding, many patients continue to experience variability in their INR values, suggesting there are other factors that can alter the INR that have not been fully described. The cases presented here demonstrate that stressful events, physical or psychological, can elevate the INR. The mechanism for this occurrence is unknown, but may be related to decreased metabolism of warfarin during stress. CONCLUSIONS: When an unexplained INR value exists, a stressor should be evaluated as a potential cause.

Abstract P6: Vitamin K Antagonist Dosing Methods and Individual Patient Quality of INR Control in the International Active W Anticoagulation Study

2011 ◽  
Vol 4 (suppl_2) ◽  
Author(s):  
Robby Nieuwlaat ◽  
Jennifer Ng ◽  
Stuart J Connolly
Keyword(s):  
Clinical Experience ◽  
Vitamin K ◽  
Vitamin K Antagonists ◽  
Random Effect ◽  
Multivariable Analysis ◽  
Patient Characteristics ◽  
International Normalized Ratio ◽  
Anticoagulation Clinic ◽  
Evidence Based ◽  
Net Benefit

Background The net benefit of vitamin K antagonists (VKAs) depends on the time spent in the therapeutic range (TTR) for the International Normalized Ratio in individual patients. Evidence-based methods are recommended by guidelines. We assessed VKA dosing methods among ACTIVE W study sites and the association with TTR in individual atrial fibrillation patients. Methods ACTIVE W sites received a survey questionnaire after the study to assess VKA dosing methods. Univariable and multivariable linear mixed models, to account for the random effect of clinic-level survey data, were used to assess the association of dosing methods with patient TTR. Patient-level covariates in multivariable analysis were: age, sex, CHADS 2 stroke risk score, mini-mental state examination score, history of VKA use, VKA type, and use of aspirin, amiodarone and insulin. Results The questionnaire was returned by 333 of 493 ACTIVE W sites (68%) who had at least one patient randomized to VKA. Responding sites had a higher mean study TTR than non-responding sites (64 vs. 60%; p=0.0101) and were mainly specialized in cardiology (87%). Only 28% of sites managed VKA dosing with an evidence-based method: an anticoagulation clinic, computer dosing system or patient self-management. Also taking in account (non-validated) manual algorithms, 64% of sites managed VKA dosing primarily based on clinical experience. In univariable analysis, patients achieved a higher TTR when managed by an anticoagulation clinic vs. by the study physician (67.3 vs. 62.1%; p=0.0027), when managed using a computer dosing system vs. using clinical experience (72.9 vs. 63.6%; p=0.0026), and when managed using at least one evidence-based method vs. not using evidence-based methods (67.3 vs. 62.8%; p=0.0045). However, when adding patient data in multivariable analysis, these three associations became non-significant (p-values 0.4659, 0.6555 and 0.6058, respectively). Conclusion The use of evidence-based VKA dosing methods was reported by only 28% of ACTIVE W sites, but was not significantly associated with an improved TTR when accounting for patient characteristics.

Warfarin Patients With Anemia Show Trend of Out-of-Range International Normalized Ratio Frequency With Point-of-Care Testing in an Anticoagulation Clinic

2018 ◽  
Vol 32 (5) ◽  
pp. 499-502 ◽  
Author(s):  
Christina E. DeRemer ◽  
Bliss McMichael ◽  
Henry N. Young
Keyword(s):  
Regression Model ◽  
Medical Center ◽  
Point Of Care ◽  
Academic Medical Center ◽  
International Normalized Ratio ◽  
Primary Objective ◽  
Anticoagulation Clinic ◽  
Care Practice ◽  
Study Results ◽  
The Impact

Introduction: Many factors influence international normalized ratio (INR); however, few studies have examined the impact of anemia in warfarin patients. The primary objective of this study was to explore the relationship between in-clinic anemia and the control of INR within an anticoagulation clinic. Methods: A retrospective chart review was performed on a random sample of patients seen in an academic medical center pharmacy-managed anticoagulation clinic. Hemochron® Signature Elite machine was utilized to monitor point-of-care (POC) INR. In-clinic anemia was defined as hematocrit <32%. Statistical analyses were conducted using STATA MP a webbased platform ( https://www.stata.com/statamp/ ). Results: Of the 300 patients analyzed, 45 (15%) patients had in-clinic anemia. Patients with in-clinic anemia were more likely to be younger ( P < .05), female ( P < .05), and have a diagnosis of sickle cell disease or anemia ( P < .05). In the unadjusted logistic regression model, patients with in-clinic anemia were less likely to have an in-range INR ( OR: 0.52; 95% CI: 0.27-0.98). The adjusted regression model did not show significance. Conclusion: Study results suggest that in-clinic anemia may be more prevalent among younger, female patients prescribed warfarin, and patients diagnosed with in-clinic anemia may be a risk factor for out-of-range INR. Pharmacists practicing in anticoagulation clinics can incorporate this information into patient care practice in efforts to maintain optimal management.

scholarly journals Assessment of Anticoagulation Control Association with Warfarin Knowledge and Demographic Features of Iranian Population

2021 ◽  
Vol 12 (2) ◽  
Author(s):  
Mohammad Esmaeel Zangenehfar ◽  
Iman Harirforoosh ◽  
Bahram Mohebbi ◽  
Zahra Khajali
Keyword(s):  
Heart Valves ◽  
Health Care Systems ◽  
Therapeutic Index ◽  
International Normalized Ratio ◽  
Cross Sectional Study ◽  
Anticoagulation Clinic ◽  
Prosthetic Heart Valves ◽  
Cross Sectional ◽  
Vein Thrombosis ◽  
Anticoagulation Control

Background: Warfarin is the most commonly used oral anticoagulant for patients with atrial fibrillation, prosthetic heart valves, and deep vein thrombosis with a narrow therapeutic index. Due to the importance of patients’ adherence to treatment and also regular measurements of International normalized ratio (INR), this can have a significant impact on the quality of anticoagulation control. Objectives: The primary aim of this study was to assess the association between warfarin knowledge and time in therapeutic range (TTR) in patients on warfarin anticoagulation for at least 6 months who were referred to anticoagulation clinic in Rajaie Heart Center during 2016 - 2017. Methods: In this cross-sectional study, 620 patients who had been referred to the outpatient Rajaie Hospital anticoagulant clinic and had been taking warfarin for over six months were asked to fill two questionnaires named anticoagulation knowledge assessment (AKA) during a 12-week period. After obtaining the necessary permits, TTR (by Rosendal method) was calculated using the INR results of patients. Results: A total of 620 patients completed the questionnaire. The relation between warfarin knowledge and anticoagulation control was not significant. The mean age of the study population was 52.45 SD ± 14.01 years. This study showed a significant relationship between TTR, duration of warfarin usage (PV = 0.03) and the underlying cause of this usage (PV = 0.016). Conclusions: Prevention of chronic diseases is one of the most important priorities of the health care systems. Reduction in complications such as thrombosis and bleeding can be achieved by efforts to promote patient’s knowledge. By recognition of relation between warfarin knowledge and social and demographic indicators, patient’s education gap can be detected and also planned for dissolving. This study showed that although many of the patients visited in anticoagulation clinic have poor anticoagulation control, but a major part of them have good knowledge of warfarin usage.

Evaluation of Differences in Percentage of International Normalized Ratios in Range Between Pharmacist-Led and Physician-Led Anticoagulation Management Services

2013 ◽  
Vol 28 (3) ◽  
pp. 249-255 ◽  
Author(s):  
Vasudha Gupta ◽  
Stephen J. Kogut ◽  
Sarah Thompson
Keyword(s):  
Chart Review ◽  
Group Versus ◽  
Retrospective Chart Review ◽  
International Normalized Ratio ◽  
Care Organization ◽  
Management Service ◽  
Anticoagulation Management ◽  
P Values ◽  
Safety And Efficacy ◽  
Anticoagulation Management Service

Background: The safety and efficacy of warfarin depend on maintaining the international normalized ratio (INR) in an established range. Objective: The purpose was to determine whether a coordinated pharmacist-led approach improved percentage of INRs in therapeutic range in comparison to a physician-led anticoagulation management service (AMS). Methods: A retrospective chart review was conducted for patients at a multisite primary care organization. INR data for patients receiving warfarin management by a physician were collected from December 1, 2009 to May 31, 2010. These were compared to INR results from December 1, 2010 to May 31, 2011, during which patients received warfarin management from a pharmacist. The primary end points were percentage of INRs within a goal range of 2.0 to 3.0 and an expanded goal range of 1.8 to 3.2 for the physician-led group versus the pharmacist-led group. Results: The percentage of INR results within the goal range (2.0-3.0) was greater among patients in the pharmacist-led group (n = .130) than the physician-led group (n = 96; 57.5% vs 50.0%, respectively; P = .0004). The percentage of INR results <1.5 (7.3% vs 5.1%) and >3.5 (11.4% vs 7.1%) was also statistically significant in favor of the pharmacist-led AMS, with P values of .03 and .0004, respectively. Conclusion: A pharmacist-led AMS improved the percentage of INRs in range, with significantly less out-of-range results.

An analysis of the relative effects of VKORC1 and CYP2C9 variants on anticoagulation related outcomes in warfarin-treated patients

2008 ◽  
Vol 100 (08) ◽  
pp. 229-239 ◽  
Author(s):  
Lisa M. Meckley ◽  
Ann K. Wittkowsky ◽  
Mark J. Rieder ◽  
Allan E. Rettie ◽  
David L. Veenstra
Keyword(s):  
Clinical Outcomes ◽  
Therapeutic Range ◽  
Maintenance Dose ◽  
Cohort Analysis ◽  
International Normalized Ratio ◽  
Anticoagulation Clinic ◽  
Bleeding Events ◽  
Stable Dose ◽  
Dose Time ◽  
Clinic Visits

SummaryThe objective of this study was to assess the relative influence of VKORC1 and CYP2C9 genetic variants on several clinical outcomes related to warfarin treatment. We conducted a retrospective cohort analysis of 172 anticoagulation clinic patients followed from warfarin initiation. We assessed the following clinical outcomes: time to stable dose; time in, above, and below therapeutic range; the probability of overanticoagulation (international normalized ratio [INR] >5); frequency of anticoagulation clinic visits; and the contribution of genetics to maintenance dose. Patients with CYP2C9 variants, compared to those without, achieved stable dose 48% later (p<0.01),spent a higher proportion of time above range in the first month of therapy (14% vs. 25%, p=0.07), and had a higher odds ratio (OR) of an INR >5 (OR: 4.15, p=0.03). In contrast, the only statistically significant effect withVKORC1 was a higher odds of an INR >5 (OR: 4.47,p=0.03) for patients homozygous for theVKORC1 low-dose haplotype (AA) compared to heterozygotes. We did not detect an influence of CYP2C9 norVKORC1 on the frequency of clinic visits. CYP2C9 alone,VKORC1 alone, and a combination of genetic and clinical factors explained 12%, 27%, and 50%,respectively, of the variation in warfarin maintenance dose. In conclusion, genetic variation in VKORC1 appears to have a different influence than CYP2C9 on anticoagulation-related outcomes such as bleeding events and time in therapeutic range. This difference may be due, in part, to pharmacokinetics factors (e.g. drug half-life), which are influenced primarily by CYP2C9; these findings should be confirmed in additional studies.

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