Patient Self-Management of Warfarin

[Guest]

There have been several studies that showed warfarin clinics to do a better job of managing warfarin than physicians.

Some people self-test their INR and then call the results to their physician or anticoagulation clinic for warfarin dosage adjustment.

Now there is a study from London showing that patients who self-test AND adjust their own warfarin doses do a better job than even the warfarin clinics.

Br J Haematol. 2006 Mar;132(5):598-603. Links


A randomised control trial of patient self-management of oral anticoagulation compared with patient self-testing.

Gardiner C, Williams K, Longair I, Mackie IJ, Machin SJ, Cohen H.

Department of Haematology, University College London Hospitals, London, UK.

Summary Several studies suggest that patient self-management (PSM) may improve the quality of oral anticoagulation therapy as measured by time spent within the international normalised ratio (INR) target range. We performed a prospective randomised control trial to determine whether the improvement in quality of treatment afforded by PSM is greater than that achieved by patient self-testing (PST) alone. A total of 104 of 800 eligible patients aged 22-88 years (median = 59.8), attending our hospital anticoagulant clinic and receiving long-term warfarin for >8 months agreed to participate. Patients were randomised to PSM (n = 55) or PST (n = 49). Both groups measured their INR using the CoaguChek S every 2 weeks or more frequently if required, for a period of 6 months. Seventy-seven of 104 (74%) patients completed the study (PSM = 41 and PST = 36). The 'drop out' rates for both groups were similar. There was no significant difference between the percentage time in target therapeutic range for PSM (69.9%) and PST (71.8%). Both groups combined showed a significant improvement over the previous 6 months (71.0% vs. 62.5%; P = 0.04). Changes in time within the therapeutic range in individual patients (+5.86) also showed a significant difference. The quality of warfarin control in both PST and PSM may be superior to that achieved by conventional management in a specialised hospital anticoagulation clinic.

 

[Georgia]

Interesting, Al.

Were that I could convince folks around here to let me self-test.

Some questions came to mind - primarily regarding the mentality of those who agreed to be in the study - my guess is that they're the most assertive patients who are interested in their health, with a take-charge mentality. It seemed that the median age was also young.

I've met quite a few coumadin patients who seem to think there's something wrong with me for being feisty (for lack of a better word) about my warfarin management - they all say something like, "oh, I just do what the doctor says and I'm fine." They don't know anything about their range, their inr, Vit K or anything. They like it that way.

Something I'm curious about - in your clinic, what's the distribution of patients' ages? Are they mostly elderly?

Thanks for posting this.

 

[Karlynn]

Georgia, ask your doctor if you were to become diabetic if he would require you to come in 2 to 3 times a day to get your blood sugar tested and then wait for him or his nurse to give you your insulin dose. If he says no, then ask him why he won't let you home test and just call in your INR (you wouldn't even be asking to take over your dosing.) I'm assuming you like your doctor, but his attitude on home testing would be one that would cause me to find another doctor. It tells me that he holds to archaic and possibly outdated information on warfarin and I would want someone up to date enough to understand that home testing is a good thing. My cardiologist has a sticking point on warfarin vs. Coumadin and won't prescribe generic. But she had her PA call me a few weeks ago to ask where I got my home testing unit because she had some other patients who she'd like to encourage to home test.

Thanks for the article Al. I know there will always be people who are in need of clinics for their warfarin management. It's the doctors that assume that their patient shouldn't be trusted to do any of the testing and management on their own that frost me.

When I began home testing about 4 years ago, it wasn't a problem of "Would I be capable of home testing?", but "Can I afford the machine and what will the insurance company do?" I always had the support of my cardio to pursue the issue. There was never a thought or question in her mind whether I'd be capable of doing it. There better not have been! I was 43 at the time! If I wasn't capable of home testing, then how the heck did I get 2 kids raised to adulthood?

 

[Emma]

Thanks for that Al.
Chloe is a good example of how home testing and dosing works too!

For the 2 years we were under hospital bloods or hospital dosing, she had erratic INR's and 3 admissions due to INR going either too high or too low!...
...For the past almost 3 years, since I started tested her and started self dosing (whether her hospital liked it or not) ... very stable INR's and NO hospital admissions since!

Emma
xxx

 

[Guest]

The average age at my clinic is about 70. They are largely retired union workers from a steel mill. They don't mind doing what we tell them but are not used to taking much initiative.

 

[jeffp]

Another interesting read - never even knew that that journal existed, now you got me lookin' through the back issues!
I self test and dose, to the dismay of my PCP; after being whip sawed around for the first 3 months, I've had much better luck than he has at keeping the INR within range. His problem is he gets real freaked when it's out of range. Being younger than his usual warfarin patients, I'm not as worried if it gets to 5 or so. He makes suggestions, and I promise to follow them dutifully, but in reality, I'm not holding doses for days for the little blips in INR. (Don't tell anyone ) The new cardiologist feels if it works for me - he's OK with it.

 

[Blanche]

Georgia:
I am one of those feisty people. Let's start a club!!!

You might tell those who are critical of you about my dear one. He was on anticoagulation for 10 years, 1 month, and 15 days when he had a stroke because of what the doctors termed, "coumadin failure." (INR less than 2.0)

In all that time, he never asked any questions, didn't know and INR from an IRA and thought that p/t has something that the astronauts drink!!!!

So far, since his initial stroke, every doctor who sees Al has said that he probably would not have had the stroke had he tested more frequently. Yet, he followed their directions and tested every 4 weeks. He was due to test at the lab the day after his stroke.

There just must be someway for you to get a home-monitor. I have articles and the like. The very doctor who initially refused to treat Albert with the home-monitor, 5 years ago, now has an Anticoagulation Clinic in his office. If I can help, let me know.

Blanche

 

[Gemma]

Interesting to have an up-to-date study Al, thanks. The one we tried to convince Jim's GP & anti-coag clinic with when he first got his Coaguchek S was from about 2002 I think.

...For the past almost 3 years, since I started tested her and started self dosing (whether her hospital liked it or not) ... very stable INR's and NO hospital admissions since!

Emma
xxx

Emma, how did that come about exactly? Did you just decide to take matters into your own hands, or did you have Chloe's GP on side?

Jim home tests more frequently than he goes to his doctor for blood draws (which are then sent to the anti-coag clinic, who then decide if his dosage needs changing!) but we couldn't convince either of them to let him just home-test and call in with his results (we weren't even trying to get them to agree to self-management 'cos we thought it'd be a bridge too far for them to get their heads around). Between them they came up with some bizarre excuse about either A) PCT funding or B) the GP or haematologist (depending on which one you spoke to) not wanting to take responsibility for that kind of testing. Even though both agree his results are close enough to the hospital lab results to be acceptable .

In reality I think it has to do with them not having time or staff to take phone calls from self-testing patients and work out dosages. Ironic really cos I'm sure if they let the capable patients self-test/manage, they'd have more time to spend on the ones who are too infirm, unsure, or who just prefer to spend their time sitting in hospital waiting rooms.

I wonder if Jim just started self-managing and didn't bother going to blood tests at his doc's any more would they do anything?!? I suppose they could refuse to give him his prescriptions until he'd had a test (although that would seem a bit unethical!)... Just speculating really - I've been trying to book his next blood draw (6th March) since last week, and each time I call they tell me they book less time ahead. It's gone from 6 weeks to 4 weeks to less than 2 weeks! And no doubt if I do leave it until 2 weeks ahead they'll be full up and not be able to fit him in.

Anyway, I'll have a talk to him later - he was going to go and see his GP some time anyway, to ask about rearranging the order of his drugs on his prescription (if the different mg warfarins are on different pages, they're charged as 2 prescriptions, if they all fit on one page it's just one!) so maybe he could test the water again about self-management. It'd certainly make his boss happier too as he's always an hour late for work after going to the blood draw.

Oh, his GP also said one time that as there was a warfarin replacement coming up in the next couple of years it should make Jim's life easier (in other words, if I make something up that sounds good, will you please get off my case?!). I presume he was referring to Exanta, which has never even been considered for mechanical valvers. AAAGGGHHH!!! See what happens when I have a day off work?! Now my brain hurts! Sorry for the rant!!

 

[Emma]

Gemma,
We are under a local coag clinic who are more than happy with me self dosing, all the while knowing they are they for me should I ever need a hand with anything.
I ring the clinic with every second coaguchek result (so every month roughly) just so they have a check on how shes doing but they don't dose her, just take note of it to keep on record. She has venus bloods every 6 months to check the machine too, as they don't like it going any longer than that... fair enough!
Theyre happy with it as they have seen all the muckups Clos cardi unit made with her dosage when they didnt listen to me about how fast she reacts to warfarin. So I'm happy doing it alone. After 5 years I should know a bit about warfarin surely??

Surprised Jim has to have regular bloods and dosing still cos even when Chloe was under her hospital for INR they let us just ring whenever we did coaguchek and let us venus blood whenever I felt appropriate. Perhaps your clinic is slightly more conservative or less trusting of coaguchek???

xxx

 

[Guest]

Verifying the CoaguChek every 6 months is a good idea. We do a check about every three months. Twice a year the hematology supervisor from the lab draws blood from 5 people and we check it on the two testers that we are currently using. Then she takes the blood to the lab and checks it with their tester. The twice a year the Wisconsin State Hygienic Lab sends us 5 unknown samples. We test these on one of our testers and send the results to them. We just got the latest results back yesterday -- 100%.

 

[Gemma]

Gemma,

Surprised Jim has to have regular bloods and dosing still cos even when Chloe was under her hospital for INR they let us just ring whenever we did coaguchek and let us venus blood whenever I felt appropriate. Perhaps your clinic is slightly more conservative or less trusting of coaguchek???

xxx

I think it's a case of both being true although the PCT funding allegedly plays a part (the haematologist said she has some PRIVATE patients who home test (!)). Although they know Jim uses a home tester and agree it's accurate, they won't accept his results in the way you described with Chloe. He hasn't actually had a dosage change since about 18 months ago I think, so it's just a question of recording an in-range result and sending his record book back every time he has a test! Just think it would be so much easier to let them know he's in range and doesn't need a test or something, but someone somewhere along the line can't get their heads round how to work it out...

It's just basically all really weird and every time I think about it I can't quite figure out who's behind the refusal to believe/accept his results. I know there are loads of people in the UK whose clinics let them home test. Just hope that when we buy a house together we can tell our new doctor (cos we can't afford a house in the catchment area of our current GPs surgeries) Jim home tests and leave it at that! No harm in dreaming!

 

[ccrawford]

This is a fasinating thread on one of my favorite topics ! My first comment is that they couldn't have done this study in the U.S. because self dosers are rare as hen's teeth. For that matter, you can go to some fairly major cities only to find there is not a cardiology clinic or coumadin clinic that uses finger stick testing. Pretty amazing. I'm only guessing but maybe the national health care system in GB and a related shortage of personnel may have something to do with self test popularity. Maybe the US propensity to file malpractice suits also has something to do with it - I know my cardio still considers my coumadin management to be his ultimate responsibility even though he hasn't overruled one of my self dosing decisions in the last three years. Heaven forbid, but if I would ever go back to having someone else test and dose, I'd opt for a clinic with finger prick. Why? because that is all they do and they know more about Coumadin management than the cardios.

 

[perkicar]

From theheart.org website

From theheart.org website

Article about self management of warfarin:

Self-monitoring warfarin gives better outcomes

Feb 2, 2006 Sue Hughes

Oxford, UK - Self-monitoring warfarin therapy enables patients to remain inside the therapeutic range more easily, which translates into fewer thromboembolic events, lower mortality, and fewer bleeding complications, a new meta-analysis has shown [1].

The meta-analysis, published in the February 4, 2006 issue of the Lancet, included 14 trials with a total of 3049 patients who were randomized to self-monitoring or routine anticoagulation. Results showed that self-monitoring led to a 55% relative reduction in thromboembolic events, a 39% relative reduction in all-cause mortality, and a 35% relative reduction in major hemorrhage.

Lead author Dr Carl Heneghan (University of Oxford, UK) commented to heartwire: "While there will obviously be many older patients who are not suitable for self-monitoring, such as those with manual-dexterity or memory problems, most younger patients on warfarin would be good candidates, and they would receive all the medical benefits we found, as well as the enormous lifestyle benefits, such as independence and freedom of travel."

Heneghan noted that many children and young people are on warfarin now for life, having received artificial heart valves, and these would be the first obvious candidates for self-monitoring. He also pointed out that although atrial fibrillation, for which warfarin is given, generally affects older people, it can start in those in their 40s or 50s; these patients would also be good candidates for self-monitoring.

In the paper, the authors note that self-monitoring of anticoagulation seems like a good idea but that published guidelines state that there are no reliable clinical-outcome data in any of the published studies to lend support to its use. They therefore conducted a systematic review of the literature to assess current evidence for the effectiveness of self-monitoring and self-adjustment of oral anticoagulation treatment.

Self-monitoring involves putting a blood sample from a finger prick on a test stick and using a machine to get an INR value. Patients can then either adjust the dose of warfarin themselves using prepared guidelines or can phone the clinic to receive the appropriate dose adjustment. The current meta-analysis found that patients who self-tested and self-dosed had fewer thromboembolic events and lower mortality than those who only self-monitored.

Self-monitoring vs routine anticoagulation: Odds ratio (OR) of major events


Event
OR
95% CI

Thrombotic events
0.45
0.30-0.68

All-cause mortality
0.61
0.38-0.98

Major bleed
0.65
0.42-0.99




Self-monitoring and self-dosing vs routine anticoagulation: Odds ratio of major events


Event
OR
95% CI

Thrombotic events
0.27
0.12-0.59

All-cause mortality
0.37
0.16-0.85

Major bleed
0.93
0.42-2.05




To download tables as slides, click on slide logo below

"There is a turning point coming in the management of patients with chronic diseases, where the patients themselves play a much greater role in managing their own treatment," Heneghan said. "We now have the evidence to show that self-monitoring warfarin is safe and effective, and it is no different from self-monitoring glucose, which diabetics have been doing for years," he added. He also noted that more effort needs to be directed at training programs for self-monitoring warfarin; these are not widely available at present.

Heneghan also pointed out to heartwire that these results are all the more important given the difficulty in finding a replacement for warfarin. "Even with all its drawbacks, warfarin remains the anticoagulant of choice for most patients, so anything we can do to optimize its use must be welcomed," he commented.




A personal account
In an accompanying "personal account" published in the same issue of the Lancet [2], a patient describes how self-monitoring warfarin therapy has allowed her to continue to lead an active life. Evelyn Richardson, 65, a retired music teacher, was prescribed lifelong warfarin in 1992 after having had two deep vein thromboses, but self-monitoring has enabled her travel to remote parts of the world and to spend the summer sailing. "I would recommend portable monitoring to anyone who travels a lot, who feels able to control their own warfarin dosage, and who does not mind adding the machine, which is rather smaller than a hardback, to their luggage. It gives me freedom and, above all, peace of mind," she says.










Sources


Heneghan C, Alonso-Coello P, Garcia-Alamino J M et al. Self-monitoring of oral anticoagulation: A systematic review and meta-analysis. Lancet 2006; 367:404-411.
Richardson E. Self-monitoring of oral anticoagulation. Lancet 2006; 367:412.






Related links


Warfarin underuse after MI and ACS: A question of underestimated benefits and perceived inconvenience
[HeartWire > News; Aug 15, 2005]

Patient management of anticoagulation feasible
[HeartWire > News; Oct 25, 2003]

 

[ccrawford]

I had a chance to talk to my cardio about the above mentioned study and I asked him how he thought the results came out. He correctly predicted the results. Because the patient is more fully aware of all the things he/she did during the last few days or weeks and the convenience of home testing, they beat the clinic and the cardio. The clinic beats the doc because that is all they do and therefore do it better. The doc comes in last because he rarely does it and is too busy to get good at it. Seems simple, but there is a lot of things that affected the results. I like the suggestion of using the diabetes example while trying to convince your doc. Go to it !!

 

[Guest]

My own PCP (and I've heard it about other docs, too) said that his malpractice insurance people told him that they were happy that he uses an anticoagulation clinic because they do a better job than most doctors and that lowers the risk that the insurance company will have to make a payout.

 

[Marty]

? % of people able to self dose

? % of people able to self dose

I of course agree with all the above. However I once asked a DuPont Coumadin rep at a medical meeting this question. What percentage of patients on Coumadin could become qualified to self monitor and self dose?
He said they did a little trial of this ( and this would be at least 10 years ago) at the University of North Carolina. Answer: about 15% of patients. This is hearsay and old hearsay. Does Al or anybody else have more recent info? I think the percentage may be higher now with more people working with computers etc but I don't think Al's clinic will be going out of business any time soon.

 

[ccrawford]

Marty, I agree its not for everybody, but don't have a clue as to what percentage might adapt well. I suspect the answer may lie in the UK and Germany where self management appears to be much more prevalent. I know some warfarin users who have no interest whatsoever in doing it themself and in general are not proactive about their medical care.

 

[Georgia]

Yup - they're the ones with good veins!

 

[RCB]

Not All

Not All

Yup - they're the ones with good veins!

I have great veins, that don't roll( Al can tell us about that ), so much that as soon as I roll my sleeve up the "blood stickers" all get a smile on their face.

It seems to me it is as Mr. Crawford says:

"I know some warfarin users who have no interest whatsoever in doing it themself and in general are not proactive about their medical care."

Being proactive as we are here at VR.com, is an important reason to want to self-test and in keeping yourself healthy.

 

[Guest]

I think that anyone who can use the internet could manage their own warfarin.
The majority of my patients have little idea of what the internet is let alone any interest in using it.