| Summary: | 碩士 === 國立陽明大學 === 藥理學研究所 === 104 === Background and objective: Warfarin is a vitamin K antagonist widely used to prevent and/or treat thromboembolic diseases. However, because of the narrow therapeutic window of warfarin, the management of warfarin therapy is complicated by numerous factors, including drug-drug interactions, drug-food interactions, diet, lifestyle, co-morbid acute and chronic diseases, compliance and the variability of patients’ responses to warfarin therapy. Failure to provide adequate anticoagulation consistently predicts thromboembolic events, while patients who receive excessive anticoagulation are at risk of bleeding. The clinical impact of pharmacist-managed anticoagulation clinic (AC) has been well documented in many countries, but the service of anticoagulation clinic is still at the beginning stage in Taiwan and the reports of outcome evaluation are few. The pharmacist-managed anticoagulation clinic was launched at Taipei Veterans General Hospital since 2012. The purposes of this study are to measure the adequacy of anticoagulation, rates of anticoagulant-related events and associated health care resource utilizations.
Method: Patients≥20 years and received warfarin therapy at least 6 months prior and after referred to the AC were recruited from 19 July 2012 to 31 December 2015. Information on demographics, indication and length of warfarin therapy, INR values, thromboembolic or bleeding events, emergency department (ED) visits or hospitalizations were collected through retrospective chart review. Differences were analyzed using paired t-test.
Results: Among 67 patients, 52.2% were male, with a mean age of 65.813.5 years. The most common indications for warfarin use were mechanical valve replacement (49.3%) and atrial fibrillation (28.4%). The total time in therapeutic range (TTR) was significantly greater during AC care compared with the period before referral (39.0% vs. 49.3%, p=0.015); the proportion of INR<1.5 was significantly lower during AC management (43.4% vs. 35.0%, p=0.009), but there was no significant difference in INR ranges between 4.5-10 (1.3% vs. 1.4%, p=0.479) and INR>10 (0.2% vs. 0.2%, p=0.431); the monitoring frequency of INR was approximately every 48.7 days. The incidence rate of thromboembolic events (1 event vs. 0 event) and major bleeding events (4 events vs. 0 event) occurred significantly less during AC management, but there were no significant difference in minor bleeding events (23 events vs. 26 events, p=0.303); the warfarin-related ED visits and hospitalizations were also significantly less during AC management (8 events vs. 1 event, p=0.026).
Conclusion: The pharmacist-managed anticoagulation clinic achieved significantly better TTR and reduced rates of thromboembolic events, major bleeding events, ED visits and hospitalizations.
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