title: Excessive anticoagulation with warfarin or phenprocoumon may have multiple causes.
abstract: BACKGROUND
  Excessive anticoagulation with vitamin K antagonists is a serious condition with a substantial risk of an adverse outcome. We thus found it of interest to review a large case series to characterize the underlying causes of excessive anticoagulation.
  
  
  METHODS
  Patients were identified both retrospectively and prospectively. The inclusion criteria were an international normalized ratio (INR) > 6.5 or INR > 3.5 and significant bleeding. Patient charts were reviewed for a predefined set of possible causes: Drug-drug interactions, alcohol abuse, disease, start-up or recent change in dosage and dosage errors.
  
  
  RESULTS
  In 86 of 107 admissions one or more causal event were identified. The two most common causes of excessive anticoagulation were disease and drug-drug interactions. The two most common drug-drug interactions were with paracetamol and tramadol. In 44 admissions, a single cause was identified; in 42, two or more causes were identified.
  
  
  CONCLUSIONS
  Although it is difficult to identify single initiatives that may reduce the number of admissions due to excessive anticoagulation, interesting areas include a stronger focus on frequent INR control during the various states of disease and heightened attention to drug-drug interactions.
  
  
  BACKGROUND
  Not relevant.
  
  
  BACKGROUND
  Not relevant.
authors.affiliation: Research Unit of Clinical Pharmacology, University of Southern Denmark, Winsløvparken 19, 2., 5000 Odense C, Denmark.
authors.forename: Peter M
authors.initials: PM
authors.lastname: Meegaard
authors.forename: Line H V
authors.initials: LH
authors.lastname: Holck
authors.forename: Anton
authors.initials: A
authors.lastname: Pottegård
authors.forename: Hanne
authors.initials: H
authors.lastname: Madsen
authors.forename: Jesper
authors.initials: J
authors.lastname: Hallas
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000925:Anticoagulants / Q000009:adverse effects*; D004347:Drug Interactions; D005260:Female; D006470:Hemorrhage / Q000139:chemically induced* / Q000209:etiology; D006801:Humans; D019934:International Normalized Ratio; D008297:Male; D010644:Phenprocoumon / Q000009:adverse effects*; D014812:Vitamin K / Q000037:antagonists & inhibitors*; D014859:Warfarin / Q000009:adverse effects*
chemical_list: D000925:Anticoagulants; D014812:Vitamin K; D014859:Warfarin; D010644:Phenprocoumon