title: 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.
authors.affiliation: Division of Hospital Internal Medicine, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224, USA. dawson.nancy11@mayo.edu
authors.forename: Nancy L
authors.initials: NL
authors.lastname: Dawson
authors.forename: Ivan E
authors.initials: IE
authors.lastname: Porter
authors.forename: Dusko
authors.initials: D
authors.lastname: Klipa
authors.forename: William R
authors.initials: WR
authors.lastname: Bamlet
authors.forename: Mary Ann
authors.initials: MA
authors.lastname: Hedges
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Maniaci
authors.forename: Jason
authors.initials: J
authors.lastname: Persoff
authors.forename: Archana
authors.initials: A
authors.lastname: Roy
authors.forename: Alden V
authors.initials: AV
authors.lastname: Patel
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D019468:Disease Management; D005260:Female; D006760:Hospitalization; D006801:Humans; D019934:International Normalized Ratio / Q000379:methods*; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D010346:Patient Care Management / Q000379:methods*; D010595:Pharmacists; D011446:Prospective Studies; D014859:Warfarin / Q000008:administration & dosage* / Q000097:blood*
chemical_list: D014859:Warfarin
references.citation: Ann Pharmacother. 2004 Dec;38(12):2115-21
references.pmid: 15522981
references.citation: J Thromb Thrombolysis. 2006 Aug;22(1):23-30
references.pmid: 16786229
references.citation: Ann Intern Med. 1997 Jan 15;126(2):133-6
references.pmid: 9005747
references.citation: Hematology. 2005 Dec;10(6):437-42
references.pmid: 16321807
references.citation: Pharmacotherapy. 2004 Aug;24(8):953-63
references.pmid: 15338843
references.citation: J Thromb Thrombolysis. 2011 Jan;31(1):22-6
references.pmid: 20396932
references.citation: Clin Geriatr Med. 2006 Feb;22(1):17-32, vii-viii
references.pmid: 16377465
references.citation: Thromb Res. 2007;119(6):705-14
references.pmid: 16844204
references.citation: Proc (Bayl Univ Med Cent). 2005 Oct;18(4):397-400
references.pmid: 16252031
references.citation: Chest. 2008 Jun;133(6 Suppl):71S-109S
references.pmid: 18574259
references.citation: Arch Intern Med. 1999 Jan 11;159(1):46-8
references.pmid: 9892329
references.citation: Semin Hematol. 2002 Jul;39(3):179-86
references.pmid: 12124680
references.citation: Am J Health Syst Pharm. 2007 Nov 1;64(21):2275-8
references.pmid: 17959580
references.citation: Ann Pharmacother. 2008 Jun;42(6):777-82
references.pmid: 18460587
references.citation: J Am Geriatr Soc. 2010 Feb;58(2):242-7
references.pmid: 20374400