C
Christine
As most know, I just completed a report writing class as part of my degree program. Stressfull would be an understatement.. my final grade/report was a recommendation report and all it's formalities (cite referencing, graphics, table of contents etc) I chose to write about Home Testing of Warfarin - recommending it. (initially I asked for feedback about comparing the two models, this topic grew from that). Included is a email I rec'd today from my professor regarding my grade for this paper. I rec'd a A- for the class but a A for this paper.
This class was both stressful and challenging as the purpose was not only to learn how to cite doc - but also to write using the least amount of words while still getting the message across and also fulfilling the minimum required pages (5).. those who know me well enough, know "digression" should be my middle name.. my worse habit is that I digress, I take the scenic route to explain something instead of the shortest. I think I had more mental meltdowns during this class then any I have taken.. I share this grade with VR.COM for participating in my inquiries and for providing support when I needed it, (especially one or two of you, you know who you are, whose last nerve I probably worked while writing this paper) - Thank You!
below is the email I rec'd today from my professor:
You certainly earned your grade, Chris. In fact, your final report was
perhaps the strongest in the class overall, as it earned you an A. I
will have it sent out to you this week so that you may see how you did.
It was a tough term for me personally and professionally, teaching 25
hours plus the online and the Chinese class with 136 students, so when I
saw work such as yours it was a breath of fresh air. I appreciate that
and thank you for your diligence.
and now, my report (minus cover page, table of contents and ref, and my formatting, including graphics..)
Introduction
Millions of Americans take warfarin -- which is also known as Coumadin -- for heart conditions to prevent the formation of blood clots that could cause strokes. It is also taken to prevent clots around replacement heart valves and to dissolve clots in the legs or lungs. (CNN). Warfarin has a narrow therapeutic margin. Any change in the amount of warfarin in a patients? bloodstream may change the way warfarin affects the patient. Too much warfarin may cause excessive internal/external bleeding, while too little could induce a stroke. It is the instability and misconceptions of the drug which deter doctors from allowing home testing to monitor and manage warfarin levels. Yet frequent home testing is one key in managing warfarin safely and effectively.
This report will discuss the misconceptions about warfarin, the importance of home testing and the different models currently available.
Warfarin
The goal of anticoagulant therapy with warfarin is to administer the lowest effective dose of the drug to maintain the target range. Certain prescription and over the counter drugs, natural health products, some foods and lifestyle are known to interact with warfarin to change the level of the drug in the patients? bloodstream. For these reasons, frequent testing to measure how the drug is working is necessary to maintain a safe therapeutic range. The measurement of which warfarin levels are based on is called PT/INR. PT stands for Prothrombin Time; the amount of time in seconds it takes for a patients? blood sample to clot. INR is the abbreviation for International Normalized Ratio, a standardized, formula driven conversion unit of measure. PT tests use different reagents depending on what lab or company supplies the test strips. INR is the converted unit of measure accepted world wide.
Until recently the only way to test INR was by a blood draw at a lab or doctors office. Because of the need for frequent testing, many patients find themselves out of range due to not testing as regularly as they should. Even now, with the new models of home PT/INR testers, some doctors are against their patient?s home testing as they fear the high risk associated with such a volatile drug.
Warfarin ? Have you had your rat poison today?
To understand why most doctors are against patient home testing, it is necessary to give a brief, and somewhat humorous, history of warfarins? early beginnings. The following excerpt was taken from Al Lodwicks? warfarinfo.com web site. (rat poison)
About 80 years ago some farmers noticed that their cattle were dying from an unknown cause. Veterinarians found that they suffered from internal hemorrhages but were not able to find a reason for several years.
At that time farmers cut hay and placed it in silos. The smell of new-mown hay is largely from a chemical known as coumarin. This particular year was hotter and wetter than usual, resulting in a particularly high coumarin level. In the silo, the heat, pressure and high coumarin level allowed a chemical reaction to take place which created an anticoagulant. When the cows ate the silage, their blood was not able to coagulate normally and they bled to death.
There were no large pharmaceutical research centers in those days. Physicians thought it would be nice if they could give the chemical to people who had blood clots, but they had no way of determining the dose. So it was used for rat poison. The Wisconsin Alumni Research Foundation supported much of the work, hence the name warfarin.
Many years later, pharmaceutical companies have standardized the drug and research has determined the need for frequent monitoring. It is the instability and long term misconceptions, or myths, of this drug which guide a doctor?s opinion to not allow home testing. I myself have been denied home testing in the past. My doctor tried to instill fear by asking if I realized I was taking rat poison. Soon after, I switched doctors.
Warfarin ? Why people are so afraid of it?
Even though 4 decades have passed since warfarin was introduced as an oral anticoagulant, determining the proper dosage to ensure adequate anticoagulation remains a challenge and, at times, a source of frustration. Warfarin is characterized by a complex dose-response relationship in which the maintenance dosage required to achieve desired anticoagulation varies greatly among individuals. Some of this variability is attributed to differences in consumption of vitamin K-containing food or to production of vitamin K by gut bacteria, a process that is greatly inhibited by antibiotics. Another source of variability is how different medications interact in the metabolism of warfarin. (medscape) It is the ever changing variables which have instilled fear and frustration in the lives of doctors and patients. Over time half truths in the risks of warfarin have turned into preconceived facts. Today, through research and patient education, these half truths, myths, are now being disputed and retested.
Warfarin Myths
Warfarin myths have been around since the introduction of the drug. Many doctor and patient fears are based on outdated research. Based on my own experience and those on Valvereplacement.com forum, we have been told by medical professionals to use an electric shaver instead of a manual razor blade, don?t eat too many vegetables. Do not take any vitamins which contains vitamin K. Do not drink any alcohol. Do not participate in any activity in which you may fall or hurt yourself. The list goes on. (valvereplacement). All of which is misinformation. The drug needs to be respected. Many factors affect its performance, the biggest issue being consistency of the patients? lifestyle. The group on Valvereplacement.com have a saying: ?Dose the diet, don?t diet the dose?. Be consistent in diet and lifestyle. Warfarin should not dictate what a patient can and can not do; rather, warfarin should be adjusted to the patients? diet and lifestyle. The key to staying in therapeutic range is keeping the lifestyle consistent. Patient home testing on a regular basis greatly improves the patients goal of being ?in range?.
PT/INR
The test result for PT depends on the method used, with results measured in seconds and compared to the average value in healthy people. Most laboratories report PT results that have been adjusted to the International Normalized Ratio (INR). Patients on anti-coagulant drugs should have an INR of 2.0 to 3.0 for basic ?blood-thinning? needs. For some patients who have a high risk of clot formation, such as mechanical heart valve patients, the INR needs to be higher - about 2.5 to 3.5. The doctor will use the INR to adjust the patients? medication to get the PT into range. (labtestsonline.) Some patients who home test also self-dose. Contrary to some beliefs, it is not difficult to do. However the patient who decides to self-test and self-dose needs to understand how the medication works in their bloodstream, what factors affect it and follow the basic dosing procedures. The rule of thumb is if the INR is out of range, increase/decrease the weekly dose by 10-20% depending on the how large the variance is. Divide the new weekly dose by 7 days for the new daily dose. Test in a week to confirm if in range. (Dosing)
Current PT/INR monitors available for home use
At the time of this report, two monitors are currently available for home use; Protime by ITC and INRatio by HemoSense. Both models use the finger stick method and are portable. Both units utilize test strips, however, the ProTime test strips need to be refrigerated until time of use. Both units give an accurate PT/INR in under two minutes after the blood sample is applied. The basic operation of these machines is similar: when the strip reaches operating temperature a bright light appears indicating the blood should be applied. Once a drop of blood is applied to the test strip, it is drawn into the test area and mixed with reagents that cause coagulation to begin. As the blood clots, a change in the impedance of the sample occurs and is detected by the meter. The meter monitors this change, and then calculates the PT and INR. (INRatio) Both machines cost around $2000. Most insurance, including Medicare, will pay for the unit under a patients? Durable Medical Equipment plan. The main requirement for both options is the patient needs their doctors? written approval. All the necessary forms to start the process along with additional information are available on QAS?s website www.hometestmed.com. (hometestmed)
Numerous clinical trials have demonstrated that patients who self-test their INR levels on a regular schedule have fewer anticoagulation-related complications and stay within their target INR range more frequently than patients who do not self-test. A study published in The Lancet in February 2006 evaluated data from 14 randomized clinical trials of self-testing. Results demonstrated significant benefits from self-testing compared with conventional lab testing: Self-testing reduced the risk of blood clots by 55% and lowered the risk of major bleeding complications by 35%. (St. Jude).
Conclusion
It is my recommendation that patient self testing and at times patient self dosing be permitted. Today?s technology has vastly improved on home testing monitors allowing the patient more control and flexibility in managing their warfarin therapy. I also recommend patient education on the variables of the medication by their doctor. This is a drug which needs to be respected, yet through education and self-management; it is one which can be used safely and effectively. As noted previously, patients who were allowed to self-manage had fewer thromboembolic events and lower mortality then those who were not. (medicalnewstoday).
Thank you again for your help and support, I may not say it often, but I do appreciate your support!
Chris
This class was both stressful and challenging as the purpose was not only to learn how to cite doc - but also to write using the least amount of words while still getting the message across and also fulfilling the minimum required pages (5).. those who know me well enough, know "digression" should be my middle name.. my worse habit is that I digress, I take the scenic route to explain something instead of the shortest. I think I had more mental meltdowns during this class then any I have taken.. I share this grade with VR.COM for participating in my inquiries and for providing support when I needed it, (especially one or two of you, you know who you are, whose last nerve I probably worked while writing this paper) - Thank You!
below is the email I rec'd today from my professor:
You certainly earned your grade, Chris. In fact, your final report was
perhaps the strongest in the class overall, as it earned you an A. I
will have it sent out to you this week so that you may see how you did.
It was a tough term for me personally and professionally, teaching 25
hours plus the online and the Chinese class with 136 students, so when I
saw work such as yours it was a breath of fresh air. I appreciate that
and thank you for your diligence.
and now, my report (minus cover page, table of contents and ref, and my formatting, including graphics..)
Introduction
Millions of Americans take warfarin -- which is also known as Coumadin -- for heart conditions to prevent the formation of blood clots that could cause strokes. It is also taken to prevent clots around replacement heart valves and to dissolve clots in the legs or lungs. (CNN). Warfarin has a narrow therapeutic margin. Any change in the amount of warfarin in a patients? bloodstream may change the way warfarin affects the patient. Too much warfarin may cause excessive internal/external bleeding, while too little could induce a stroke. It is the instability and misconceptions of the drug which deter doctors from allowing home testing to monitor and manage warfarin levels. Yet frequent home testing is one key in managing warfarin safely and effectively.
This report will discuss the misconceptions about warfarin, the importance of home testing and the different models currently available.
Warfarin
The goal of anticoagulant therapy with warfarin is to administer the lowest effective dose of the drug to maintain the target range. Certain prescription and over the counter drugs, natural health products, some foods and lifestyle are known to interact with warfarin to change the level of the drug in the patients? bloodstream. For these reasons, frequent testing to measure how the drug is working is necessary to maintain a safe therapeutic range. The measurement of which warfarin levels are based on is called PT/INR. PT stands for Prothrombin Time; the amount of time in seconds it takes for a patients? blood sample to clot. INR is the abbreviation for International Normalized Ratio, a standardized, formula driven conversion unit of measure. PT tests use different reagents depending on what lab or company supplies the test strips. INR is the converted unit of measure accepted world wide.
Until recently the only way to test INR was by a blood draw at a lab or doctors office. Because of the need for frequent testing, many patients find themselves out of range due to not testing as regularly as they should. Even now, with the new models of home PT/INR testers, some doctors are against their patient?s home testing as they fear the high risk associated with such a volatile drug.
Warfarin ? Have you had your rat poison today?
To understand why most doctors are against patient home testing, it is necessary to give a brief, and somewhat humorous, history of warfarins? early beginnings. The following excerpt was taken from Al Lodwicks? warfarinfo.com web site. (rat poison)
About 80 years ago some farmers noticed that their cattle were dying from an unknown cause. Veterinarians found that they suffered from internal hemorrhages but were not able to find a reason for several years.
At that time farmers cut hay and placed it in silos. The smell of new-mown hay is largely from a chemical known as coumarin. This particular year was hotter and wetter than usual, resulting in a particularly high coumarin level. In the silo, the heat, pressure and high coumarin level allowed a chemical reaction to take place which created an anticoagulant. When the cows ate the silage, their blood was not able to coagulate normally and they bled to death.
There were no large pharmaceutical research centers in those days. Physicians thought it would be nice if they could give the chemical to people who had blood clots, but they had no way of determining the dose. So it was used for rat poison. The Wisconsin Alumni Research Foundation supported much of the work, hence the name warfarin.
Many years later, pharmaceutical companies have standardized the drug and research has determined the need for frequent monitoring. It is the instability and long term misconceptions, or myths, of this drug which guide a doctor?s opinion to not allow home testing. I myself have been denied home testing in the past. My doctor tried to instill fear by asking if I realized I was taking rat poison. Soon after, I switched doctors.
Warfarin ? Why people are so afraid of it?
Even though 4 decades have passed since warfarin was introduced as an oral anticoagulant, determining the proper dosage to ensure adequate anticoagulation remains a challenge and, at times, a source of frustration. Warfarin is characterized by a complex dose-response relationship in which the maintenance dosage required to achieve desired anticoagulation varies greatly among individuals. Some of this variability is attributed to differences in consumption of vitamin K-containing food or to production of vitamin K by gut bacteria, a process that is greatly inhibited by antibiotics. Another source of variability is how different medications interact in the metabolism of warfarin. (medscape) It is the ever changing variables which have instilled fear and frustration in the lives of doctors and patients. Over time half truths in the risks of warfarin have turned into preconceived facts. Today, through research and patient education, these half truths, myths, are now being disputed and retested.
Warfarin Myths
Warfarin myths have been around since the introduction of the drug. Many doctor and patient fears are based on outdated research. Based on my own experience and those on Valvereplacement.com forum, we have been told by medical professionals to use an electric shaver instead of a manual razor blade, don?t eat too many vegetables. Do not take any vitamins which contains vitamin K. Do not drink any alcohol. Do not participate in any activity in which you may fall or hurt yourself. The list goes on. (valvereplacement). All of which is misinformation. The drug needs to be respected. Many factors affect its performance, the biggest issue being consistency of the patients? lifestyle. The group on Valvereplacement.com have a saying: ?Dose the diet, don?t diet the dose?. Be consistent in diet and lifestyle. Warfarin should not dictate what a patient can and can not do; rather, warfarin should be adjusted to the patients? diet and lifestyle. The key to staying in therapeutic range is keeping the lifestyle consistent. Patient home testing on a regular basis greatly improves the patients goal of being ?in range?.
PT/INR
The test result for PT depends on the method used, with results measured in seconds and compared to the average value in healthy people. Most laboratories report PT results that have been adjusted to the International Normalized Ratio (INR). Patients on anti-coagulant drugs should have an INR of 2.0 to 3.0 for basic ?blood-thinning? needs. For some patients who have a high risk of clot formation, such as mechanical heart valve patients, the INR needs to be higher - about 2.5 to 3.5. The doctor will use the INR to adjust the patients? medication to get the PT into range. (labtestsonline.) Some patients who home test also self-dose. Contrary to some beliefs, it is not difficult to do. However the patient who decides to self-test and self-dose needs to understand how the medication works in their bloodstream, what factors affect it and follow the basic dosing procedures. The rule of thumb is if the INR is out of range, increase/decrease the weekly dose by 10-20% depending on the how large the variance is. Divide the new weekly dose by 7 days for the new daily dose. Test in a week to confirm if in range. (Dosing)
Current PT/INR monitors available for home use
At the time of this report, two monitors are currently available for home use; Protime by ITC and INRatio by HemoSense. Both models use the finger stick method and are portable. Both units utilize test strips, however, the ProTime test strips need to be refrigerated until time of use. Both units give an accurate PT/INR in under two minutes after the blood sample is applied. The basic operation of these machines is similar: when the strip reaches operating temperature a bright light appears indicating the blood should be applied. Once a drop of blood is applied to the test strip, it is drawn into the test area and mixed with reagents that cause coagulation to begin. As the blood clots, a change in the impedance of the sample occurs and is detected by the meter. The meter monitors this change, and then calculates the PT and INR. (INRatio) Both machines cost around $2000. Most insurance, including Medicare, will pay for the unit under a patients? Durable Medical Equipment plan. The main requirement for both options is the patient needs their doctors? written approval. All the necessary forms to start the process along with additional information are available on QAS?s website www.hometestmed.com. (hometestmed)
Numerous clinical trials have demonstrated that patients who self-test their INR levels on a regular schedule have fewer anticoagulation-related complications and stay within their target INR range more frequently than patients who do not self-test. A study published in The Lancet in February 2006 evaluated data from 14 randomized clinical trials of self-testing. Results demonstrated significant benefits from self-testing compared with conventional lab testing: Self-testing reduced the risk of blood clots by 55% and lowered the risk of major bleeding complications by 35%. (St. Jude).
Conclusion
It is my recommendation that patient self testing and at times patient self dosing be permitted. Today?s technology has vastly improved on home testing monitors allowing the patient more control and flexibility in managing their warfarin therapy. I also recommend patient education on the variables of the medication by their doctor. This is a drug which needs to be respected, yet through education and self-management; it is one which can be used safely and effectively. As noted previously, patients who were allowed to self-manage had fewer thromboembolic events and lower mortality then those who were not. (medicalnewstoday).
Thank you again for your help and support, I may not say it often, but I do appreciate your support!
Chris
