Key result
Hospitalised patients with excessive anticoagulation (INR ≥ 5) spent 41% of their time within the target INR range, compared to 60% for patients with INR < 5.
Why the study?
Anticoagulation control is a strong predictor of clinical outcomes for patients on warfarin, but instances and causes of excessive anticoagulation in hospitalized patients are not well characterized.
What are the causes and management strategies for excessive anticoagulation (INR ≥ 5) in hospitalized patients on warfarin?
Observational (n=144)
No
What are the causes and management strategies for excessive anticoagulation (INR ≥ 5) in hospitalized patients on warfarin?
Anticoagulation control is challenging in hospitalized patients, with drug interactions such as roxithromycin co-administration being a significant contributor to excessive anticoagulation.
Answers are grounded in this paper and cite their sources.
Characterizes causes and management of supratherapeutic INRs in hospitalized warfarin patients; leaves open need for standardized protocols.
Background Anticoagulation control is a strong predictor of clinical outcomes for patients on warfarin. Aim To identify instances of excessive anticoagulation in hospitalised patients on warfarin and to determine the causes of international normalised ratios (INRs) of 5 and above and the management strategies used to correct it. Method An observational descriptive study undertaken at a teaching hospital over a 3–month period. Data were reviewed prospectively and retrospectively to measure the percentage of time patients were maintained within their target INR range while in hospital and to identify cases of excessive anticoagulation. Patients were divided into a control group (INR < 5) and a high INR group (INR = 5). Possible causes of INRs of 5 and above and its management strategies were recorded. Results Out of a total of 208 patients on warfarin identified in the geriatric, orthopaedic and cardiology wards, 144 patients met the study criteria. The mean percentage of time spent within, above and below the target INR range by the control group was 60%, 0% and 15%, and by the high INR group was 41%, 33% and 16%, respectively. In the high INR group, 26 possible causes of INRs of 5 and above were identified and the co‐administration of roxithromycin and warfarin were implicated in 7 cases. Management strategies for INRs of 5 and above were compared between two stratified groups (INR 5–9 and INR = 9). The management strategies adopted included warfarin dose reduction (83%; 86%), temporary withholding of warfarin (100%; 100%), administration of vitamin K (58%; 100%), fresh frozen plasma (13%; 43%) and prothrombin complex concentrate (8%; 29%). The time to return to the upper limit of the target INR range was INR 5–9 (1.6 SD 1.5 days) and INR = 9 (0.5 SD 0.4 days). Conclusion Anticoagulation control is difficult for hospital patients and drug interactions are an important contributing factor. The management strategies adopted to correct excessive anticoagulation followed the relevant guidelines.
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Su et al. (2008) conducted an observational in Hospitalised patients on warfarin (n=144). Excessive anticoagulation (INR ≥ 5) vs. INR < 5 was evaluated on Mean percentage of time spent within target INR range. Hospitalised patients with excessive anticoagulation (INR ≥ 5) spent 41% of their time within the target INR range, compared to 60% for patients with INR < 5.
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