Inpatient warfarin management: pharmacist management using a detailed dosing protocol

Abstract

Hospitalized patients receiving anticoagulants such as warfarin are at increased risk for adverse events because of difficulties maintaining a therapeutic international normalized ratio (INR). We sought to determine whether a detailed warfarin dosing protocol administered by pharmacists with minimal physician oversight significantly reduced the proportion of hospitalized patients with a supratherapeutic INR. We conducted a prospective, nonrandomized trial with patients on cardiology, internal medicine, and family medicine inpatient services who received at least 1 dose of warfarin while hospitalized. The baseline group included 293 patients, and the intervention group comprised 217 patients. Baseline characteristics were similar in each group, except that more patients received antibiotics in the intervention group. The defect rate (INR > 5 after receiving warfarin) in the baseline group was significantly higher than in the intervention group (7.85 vs. 1.85%). Conversely, the percentage of patients with an INR less than 1.7 after 4 warfarin doses was lower in the intervention patients, indicating overall improvement in therapeutic levels. Dosing discussions were required between the pharmacist and a physician for only 6% of intervention patients. The protocol effectively reduced overanticoagulation without increasing under anticoagulation during hospitalization and reduced the need for close physician oversight.

A systematic review on comparing 2 common models for management of warfarin therapy; pharmacist-led service versus usual medical care

“…Database searching identified 758 records, of which, 59 articles were retrieved based on abstract and title assessment. After full-text review, 35 articles were excluded because they did not compare the 2 models (n ¼ 4), [16][17][18][19] were irrelevant articles (n ¼ 3), [20][21][22] were unavailable full-text articles (n ¼ 4), [23][24][25][26] were studies from sites in Asia (n ¼ 6), [27][28][29][30][31][32] were inpatient-conducted studies (n ¼ 15), 10,11,[33][34][35][36][37][38][39][40][41][42][43][44][45] and did not report INR (n ¼ 3). [46][47][48] Finally, 24studies including 4 RCTs and 20 non-RCTs with 11 607 participants (n ¼ 662 in RCTs and n ¼ 10 945 in non-RCTs) met the inclusion criteria ( Figure 1).…”

Comparing the effectiveness of pharmacist‐managed warfarin anticoagulation with other models: a systematic review and meta‐analysis

“…However, the intervention protocol needs to be perfected and the function of pharmacist needs to be more effective. In 2012, the first study using a detailed dosing schedule for both the initiation and continuation of warfarin was published . That study and many other published literatures may be ideal references for detailed dosing recommendations and pharmaceutical care detailed.…”

Development of an Anticoagulation Stewardship Program at a Large Tertiary Care Academic Institution

“…Having pharmacists monitor these patients throughout therapy and until completion of treatment allows for interventions to be made when issues arise. [12][13][14][15] Due to the complexity involved in managing therapy, the Joint Commission (TJC) has challenged hospitals to reduce the likelihood of patient harm associated with the use of anticoagulant therapy through the National Patient Safety goals. Presently, our institution has made great strides to attain these goals but ongoing effort is essential to maintain and exceed the expectations put forth by TJC.…”