Evidence-based management of anticoagulant therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines.
BACKGROUND
High-quality anticoagulation management is required to keep these narrow therapeutic index medications as effective and safe as possible. This article focuses on the common important management questions for which, at a minimum, low-quality published evidence is available to guide best practices.


METHODS
The methods of this guideline follow those described in Methodology for the Development of Antithrombotic Therapy and Prevention of Thrombosis Guidelines: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines in this supplement.


RESULTS
Most practical clinical questions regarding the management of anticoagulation, both oral and parenteral, have not been adequately addressed by randomized trials. We found sufficient evidence for summaries of recommendations for 23 questions, of which only two are strong rather than weak recommendations. Strong recommendations include targeting an international normalized ratio of 2.0 to 3.0 for patients on vitamin K antagonist therapy (Grade 1B) and not routinely using pharmacogenetic testing for guiding doses of vitamin K antagonist (Grade 1B). Weak recommendations deal with such issues as loading doses, initiation overlap, monitoring frequency, vitamin K supplementation, patient self-management, weight and renal function adjustment of doses, dosing decision support, drug interactions to avoid, and prevention and management of bleeding complications. We also address anticoagulation management services and intensive patient education.


CONCLUSIONS
We offer guidance for many common anticoagulation-related management problems. Most anticoagulation management questions have not been adequately studied.
Division of Clinical Pharmacology and Therapeutics, McMaster University, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada; Department of Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada. Electronic address: holbrook@mcmaster.ca.
Anne
A
Holbrook
Department of Medicine, McMaster University, Hamilton, ON, Canada.
Sam
S
Schulman
Department of Pharmacy, Kaiser Permanente Colorado, Denver, CO.
Daniel M
DM
Witt
Department of Medicine, Innlandet Hospital Trust, Gjøvik, Norway.
Per Olav
PO
Vandvik
Department of Internal Medicine, University of California Los Angeles, Los Angeles, CA.
Jason
J
Fish
Department of Medicine, University of Western Ontario, London, ON, Canada.
Michael J
MJ
Kovacs
Department for Coagulation Disorders, University of Lund, University Hospital, Malmö, Sweden.
Peter J
PJ
Svensson
Department of Pharmacy, University of Washington, Seattle, WA.
David L
DL
Veenstra
Department of Medicine, McMaster University, Hamilton, ON, Canada.
Mark
M
Crowther
Department of Medicine, McMaster University, Hamilton, ON, Canada; Department of Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada.
Gordon H
GH
Guyatt
D000284:Administration, Oral; D020000:Decision Support Systems, Clinical; D004305:Dose-Response Relationship, Drug; D004334:Drug Administration Schedule; D004347:Drug Interactions; D064420:Drug-Related Side Effects and Adverse Reactions; D019317:Evidence-Based Medicine; D005343:Fibrinolytic Agents / Q000009:adverse effects / Q000493:pharmacokinetics / Q000627:therapeutic use*; D000077425:Fondaparinux; D006470:Hemorrhage / Q000139:chemically induced / Q000517:prevention & control / Q000628:therapy; D006493:Heparin / Q000009:adverse effects / Q000493:pharmacokinetics / Q000627:therapeutic use; D006801:Humans; D007262:Infusions, Intravenous; D019934:International Normalized Ratio; D008134:Long-Term Care; D010353:Patient Education as Topic; D011134:Polysaccharides / Q000009:adverse effects / Q000493:pharmacokinetics / Q000627:therapeutic use; D016032:Randomized Controlled Trials as Topic; D012648:Self Care; D012955:Societies, Medical; D013927:Thrombosis / Q000097:blood / Q000188:drug therapy* / Q000517:prevention & control*; D014481:United States; D014812:Vitamin K / Q000037:antagonists & inhibitors
D005343:Fibrinolytic Agents; D011134:Polysaccharides; D014812:Vitamin K; D006493:Heparin; D000077425:Fondaparinux