Adjustment of warfarin loading doses for age exhibits clear superiority over the use of Fenn or Emp. This becomes increasingly important as the average age of patients being warfarinised increases, with the recognition that atrial fibrillation requires anticoagulation. Fenn consistently overdosed elderly patients, especially those aged 80 years and older.
The age-adjusted dosing protocol rapidly achieved a stable INR with minimal overanticoagulation. Patients with low serum albumin levels (<3.0 g/dL) may be sensitive to the effects of warfarin during the loading phase.
We report a comparison of warfarin treatment outcomes in 172 inpatients in two general hospitals randomly assigned to commence warfarin therapy by one of two methods; the first where warfarin dosage was determined using a flexible dose induction protocol, and the other where dosage was prescribed empirically by resident medical staff. The mean INR for each treatment day, the mean time to reach a therapeutic level of INR, the mean maintenance dose and the mean time to reach maintenance dose were not significantly different between the protocol and empirical treatment groups. Although the mean observations of warfarin effect were similar between the two groups, there were more patients with excessive warfarin effect (INR greater than 4.0) during empirical treatment. In addition, age and identified complicating factors such as interfering drugs, heart failure or alcohol abuse were significant predictors of excessive warfarin effect, regardless of treatment group. The protocol dose administered on day 4 of treatment, which has been used as a determinant of maintenance dose, predicted maintenance dose to within 1 mg in 57/83 patients (69%, 95% confidence interval: 59-79%). We conclude that as a method for safely and effectively initiating warfarin therapy, this protocol at least matches the empirical prescribing skills of medical staff in a teaching hospital.
Objectives: To determine the incidence and preventability of unplanned admissions to a State acute care general teaching hospital caused by adverse medication-related events (AMREs). Methods: A cohort study of consecutive unplanned admissions to the Repatriation General Hospital Daw Park over three weeks in April and May 1996. Medication details were obtained by patient interview, referral letters and review of medical notes. If an AMRE was suspected, all investigators met and collaboratively assessed whether an AMRE had occurred. Results: Of 172 unplanned admissions, 31 (18%) possibly involved an AMRE as a primary cause. Nearly one-third were considered potentially preventable. The most common events were adverse drug reactions (58%), patients receiving too much of the correct medication (16%), and patients not receiving the prescribed medication (16%). AMREs were assessed as the probable cause of hospitalisation in 29% of all cases, possible in 58%, and unassessable in 13%. Cardiovascular and central nervous system medications were most commonly implicated. Conclusion: AMREs were significant contributors to hospitalisation in this study of an older than average population. Aust J Hosp Pharm 1999; 29: 84-7.
A commercially available 1.0 g intravenous (i.v.) dosage formulation of methylprednisolone, as the sodium hemisuccinate salt (Solu Medrol, Upjohn) was administered both parenterally and orally (pulse steroid therapy) on separate occasions, to eight elderly (mean 65 y) patients with active rheumatoid arthritis. The relative oral bioavailability of the sterol was 69.2%. Elimination of methylprednisolone was prolonged when given orally; the mean residence times were 7.23 h and 3.94 h for oral and i.v. administrations, respectively. Clinical response to pulse steroid therapy was no different with respect to route of administration. There were no significant differences in standard clinical and laboratory assessments of disease activity when the two therapies were compared. Oral administration of methylprednisolone in patients requiring high-dose pulse steroid therapy is convenient and avoids the discomfort and inconvenience associated with i.v. administration.
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