Self-monitoring and self-management of oral anticoagulation

Abstract

BACKGROUND: The introduction of portable monitors (pointof-care devices) for the management of patients on oral anticoagulation allows self-testing by the patient at home. Patients who self-test can either adjust their medication according to a predetermined dose-INR schedule (self-management) or they can call a clinic to be told the appropriate dose adjustment (self-monitoring). Several trials of selfmonitoring of oral anticoagulant therapy suggest this may be equal to or better than standard monitoring. OBJECTIVES: To evaluate the effects of self-monitoring or self-management of oral anticoagulant therapy compared to standard monitoring. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2007, Issue 4), MEDLINE, EMBASE and CINAHL (to November 2007). We checked bibliographies and contacted manufacturers and authors of relevant studies. No language restrictions were applied. SELECTION CRITERIA: Outcomes analysed were thromboembolic events, mortality, major haemorrhage, minor haemorrhage, tests in therapeutic range, frequency of testing, and feasibility of self-monitoring and self-management. DATA COLLECTION AND ANALYSIS: The review authors independently extracted data. We used a fixed-effect model with the Mantzel-Haenzel method to calculate the pooled risk ratio (RR) and Peto's method to verify the results for uncommon outcomes. We examined heterogeneity amongst studies with the Chi 2 and I 2 statistics. MAIN RESULTS: We identified 18 randomized trials (4723 participants). Pooled estimates showed significant reductions in both thromboembolic events (RR 0.50, 95% CI 0.36 to 0.69) and all-cause mortality (RR 0.64, 95% CI 0.46 to 0.89). This reduction in mortality remained significant after the removal of low-quality studies (RR 0.65, 95% CI 0.46 to 0.90). Trials of self-management alone showed significant reductions in thromboembolic events (RR 0.47, 95% CI 0.31 to 0.70) and all-cause mortality (RR 0.55, 95% CI 0.36 to 0.84); self-monitoring did not (thrombotic events RR 0.57, 95% CI 0.32 to 1.00; mortality RR 0.84, 95% CI 0.50 to 1.41). Self-monitoring significantly reduced major haemorrhages (RR 0.56, 95% CI 0.35 to 0.91) whilst self-management did not (RR 1.12, 95% CI 0.78 to 1.61). Twelve trials reported improvements in the percentage of mean INR measurements in the therapeutic range. No heterogeneity was identified in any of these comparisons.

Effect of Self-Management Program on Self-efficacy and Medication Adherence in Patients with Mechanical Heart Valve: a Randomized Clinical Trial

“…22,27 Education about anticoagulant self-management can result in the patients' satisfaction, quality of life improvement, anticoagulation control, and reduction in thromboembolic events and mortality. [28][29][30] in the present study, the mean of PT and INR were significantly higher in the intervention group in comparison to the control group. In Jeon and Park study in 2015, PT and INR were maintained in the therapeutic range, following the intervention among patients with cardiac valve replacement.…”

Patient self‐testing and self‐management of oral anticoagulation with vitamin K antagonists: guidance from the British Committee for Standards in Haematology

“…Relevant evidence of effectiveness was reported in a Cochrane systematic review of 18 randomized trials with data for 4723 participants (Garcia‐Alamino et al , ) and an individual patient data meta‐analysis including 11 trials with data for 6417 participants and 12 800 person‐years of follow‐up (Heneghan et al , ). Overall, this evidence indicates that, compared to standard monitoring, patients who self‐test or self‐manage show improved quality of their oral anticoagulation therapy.…”

“…In the 2010 Cochrane review (Garcia‐Alamino et al , ), pooled estimates of both PST and PSM strategies showed significant reductions in thromboembolic events, relative risk (RR) 0·50 (95% confidence interval [CI] 0·36–0·69) and all‐cause mortality, RR 0·64 (0·46–0·89). In those patients who undertook PSM, significant reductions in thromboembolic events (RR 0·47, 0·31–0·70) and all‐cause mortality, RR 0·55 (0·36–0·84) were reported, but not for those patients self‐testing alone: thromboembolic events RR 0·57 (0·32–1·00), mortality RR 0·84 (0·50–1·41).…”

“…The evidence for PST and PSM demonstrates improved quality of oral anticoagulation therapy compared to standard monitoring (Garcia‐Alamino et al , ; Heneghan et al , ). The current costs of suboptimal oral anticoagulation should not be underestimated and are substantial.…”

The Cochrane Database of Systematic Reviews, Issue 4, 2010

“…A new review of combined chiropractic interventions for low‐back pain includes 12 randomized trials with nearly 3000 participants (8), an updated review of exercise based rehabilitation for heart failure increased the total number of included studies from 8 to 19 (9), while the updating of the Cochrane review of hyperbaric oxygen therapy for multiple sclerosis was not able to add to the nine trials, with approximately 500 patients (10), in the previous version (11). Two other new reviews show the benefits of self‐monitoring and self‐management for patients who are taking oral anticoagulants such as warfarin (12), and the impact of legislation to ban smoking in the workplace on passive smoking and health (13).…”