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Rapid Responses: Rapid Responses published:
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Training for patients in a randomised controlled trial of self management of warfarin treatment
- Dave M Hambidge (1 March 2004)
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Re: Training for patients in a randomised controlled trial of self management of warfarin treatment
- David Syme (2 March 2004)
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Re: Re: Training for patients in a randomised controlled trial of self management of warfarin treatment
- Dave Hambidge (3 March 2004)
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Safe monitoring of self management
- Yasmin Z. Khan, Stephen F. Wilson (24 March 2004)
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Training for patients in a randomised controlled trial of self-management of warfarin treatment
- Ranjit S More (24 May 2004)
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The changing face of anticoagulation clinics in the 21st century
- Anil V Kamat (26 July 2004)
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re: The changing face of anticoagulation clinics in the 21st century
- David A Fitzmaurice (27 July 2004)
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Dave M Hambidge, Freelance Consultant Psychiatrist From Home, CW8 4QU
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The surprisingly high refusal rate to self manage, 76%, must be analysed to make sense of this otherwise helpful study. Individuals who need to monitor there own blood sugar levels are "expected" to get on with, they are not invited. Two of my neighbours who have recently developed maturity onset diabetes were peremptorarily given a blood test machine and left to it after little more than 15 minutes instruction. Obviously, being taught to then decide on insulin dose and learning to draw up and administer it is a much longer teaching task. Yet, patients are still expected to do this unless there are very good reasons why they can not. The same level of expectation by the professionals involved in teaching the use of INR monitoring must be prominent. Were the subjects put off by the cost of test strips which only became freely available on the NHS about one year ago? Had the longer standing warfarin patients been put off the possibility of self management of their INR by the unintentional attitude of the "warfarin clinic routine"? As most GP's have delegated patients to the hospital, then the process can be seen by the average patient as "so important even my GP can't do it". Sitting around the path lab waiting for your test and then the result takes ages in many places, often 30 minutes or more. This also conveys to established patients that the procedure is complex and difficult and time consuming, therefore beyond them. Finally, even if not appreciated, there is a sort of camaraderie in warfarin clinic attenders. They survive the system and support each other in doing so. I know that self management removes that as I went through it. But, the advantages so far outweigh the potential disadvantages that self management of INR must be the way forward for far more, dare I say the large majority of warfarin patients. Competing interests: I own a Coaguchek S with which I monitor my INR and warfarin dose and have done so since 1997. |
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David Syme, GP Killin Perthshire FK21 8TQ
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In the midst of a number of interesting points on INR testing, Dave Hambridge makes the assertion that "most GP's have delegated patients to the hospital". I wonder what evidence there is for this statement? Certainly, the New Contract rewards us for near-patient testing, which is mostly warfarin monitoring, and I can't see why this should be so if no- one was doing it. In our practice we have done 95% of INRs by Coaguchek for the past three years (Still send the occasional one to the lab when doing venepuncture for other reasons anyway) and I can't imagine why any patient would want to trail off to hospital and wait for ages to have this simple test preformed! Competing interests: None declared |
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Dave Hambidge, Freelance Consultant Psychiatrist From Home
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I am delighted to read about your far seeing use of Coaguchek. Regrettably at least around here in NW England, hospital Warfarin clinics are still the order of the day for most of us. But then, the Scots are so much more sensible than the English about so many things. Starting with Laphroaig, but only once a week cos of the B****Y warfarin! Dr. Dave Hambidge
Competing interests: None declared |
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Yasmin Z. Khan, Registrar Ambulatory Care Macarthur Health Service,NSW,Australia 2560, Stephen F. Wilson
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Murray et al recognise the role of self management and the opportunity for patients to take responsibility for their own health. In spite of this acknowledgement there were a large number of exclusions in their study. The client base eligible for home monitoring of Blood Sugar is much larger due to the involvement of the wider family unit and community nurses. We suggest that although titrating doses is a skill for selected patients, it also needs to be taught to carers of cognitively impaired, non-English speaking background, and complex medical or surgical patients. Implications include understanding the role of foods, medications and fluctuant doses of warfarin on the INR reading, with clear directions for seeking medical intervention. Prolonged or shortened prothrombin times are complications which require revision of dosing. This is an area which will probably need further technical development in the way of testing. The paper describes a test without a longer term indicator parallel to that of the Hba1c. Perhaps a web based recording system for quality assurance, which indicates polar readings of significance, and is compatible with laboratory software could provide the short-term solution for monitoring safe ranges. Competing interests: None declared |
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Ranjit S More, Consultant Cardiologist, Blackpool, Fylde & Wyre Hospitals NHS Trust Blackpool Victoria Hospital, Blackpool, FY3 8NR
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Dear Sirs, The increasing use of warfarin and other vitamin K antagonists within general practice is placing a considerable burden on current anticoagulation monitoring services. This correlates with a growing prevalence of atrial fibrillation and a greater appreciation of the need for stroke prevention. In recent years, patient self-management of anticoagulation has gained popularity as a possible means of both reducing this burden and improving anticoagulation control.1 The recent study of Murray and colleagues (BMJ 2004 Feb 21: 328: 437–8) therefore provides highly relevant information on the uptake of patient self-management of anticoagulation in the general practice setting. Unfortunately, the results of the study highlight several inadequacies of anticoagulation self-management, in that few patients were willing to participate (only 24% of individuals approached) and of those that did more than one quarter did not complete the required period of training. As such, self-management was only of benefit for a small proportion of highly motivated patients. Moreover, the costs involved in setting up and implementing a patient self -management system were not clear. In their study, for example, Murray and colleagues employed experienced nurses, who themselves received additional training, to provide training on self-management. Thus, costs of employment and training need to be considered. Patients on self-management also had to attend at least two training sessions, thereby potentially incurring personal costs related to travel and work absence. Clearly, if we are to realistically consider patient self-management as a robust alternative to hospital-based anticoagulation monitoring, such issues need to be taken into account. Reference 1 Piso B, Jimenez Boj E, Krinninger B, Watzke HH. The quality of oral anticoagulation before, during and after a period of patient self management. Thromb Res 2002;106:101–4. Competing interests: None declared |
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Anil V Kamat, Specialist Registrar, Haematology Department of Haematology , Guy's and St.Thomas' NHS Trust, London SE1 9RT
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Editor- Murray et al in their randomised controlled trial have shown that self management of warfarin treatment is possible but for it to become established , more training and practical support is required1. The outcome of the SMART trial ( Self management of anticoagulation: a randomised trial ) is not surprising. The patients who were randomised to self management and completed training were younger and better educated than those who did not complete training. It is interesting to note only 24% of the 2586 patients invited to participate in the trial, provided written consent. This correlates to about 7.6 out of every 10 patients attending an anticoagulation clinic, opting out of self management of warfarin anticoagulation. Though the concept of self management appears good, the practicalities involved makes it a difficult task. Elderly patients and those with neurological deficits will obviously find it challenging as well as those who might appear eligible but ‘lack interest’ or ‘ confidence’. The imminent introduction of new oral direct thrombin inhibitors in the anticoagulation armamentarium is set to change the face of anticoagulant practice. Newer oral direct thrombin inhibitors (DTIs) such as Ximelagatran and BIBR 1048 have been in clinical trials2. Ximelagatran ( ExantaTM) , a direct thrombin inhibitor which is actively metabolised to melagatran has been shown to be beneficial in both venous3,4 and arterial5 thrombosis. This drug has successfully completed the Mutual Recognition Procedure (MRP) in Europe( excluding UK and Ireland ) for short-term use in the prevention of venous thromboembolic events in major orthopaedic surgery ( hip or knee replacement)6. The entry of this drug in the UK is imminent and will be an excellent alternative to warfarin and other vitamin K antagonists. The oral DTI is administered at a fixed dosage with predictable therapeutic levels and does not require routine coagulation monitoring. The availability of an anticoagulant with an oral fixed-dose regimen without routine coagulation monitoring may simplify the prevention and treatment of thrombosis. If the oral DTIs live upto their expectations, there will certainly be pressure both from clinicians as well as patient groups for its increasing use, which will eventually phase out warfarin and with it , the anticoagulation clinics. So, it will soon be time to say ‘good-bye’ to warfarin. In the light of these developments, the self management trial (SMART) has probably come in the twilight days of warfarin. References 1.Murray E,Fitzmaurice D, McCahon D, Fuller C, Sandhur H. Training for patients in a randomisedcontrolled trial of self management of warfarin treatment.BMJ 2004;328:437-8.(21 February). 2.Gustafsson D.Oral direct thrombin inhibitors in clinical development. Journal of Internal Medicine 2003;254:322-34. 3.Eriksson BI. Clinical experience of melagatran/ximelagatran in major orthopaedic surgery. Thrombosis Research 2003;109 Suppl 1:S23-9. 4.Ericksson BI, Agnelli G., Cohen AT, Dahl OE, Lassen MR, Mouret P,Rosencher N. Kalebo P,Eskilson C, Andersson M, Freij A. EXPRESS study Group.Journal of Thrombosis & Haemostasis2003; 1:2490-6. 5 Wallentin L, Wilcox RG, Weaver WD, Emanuelsson H, Goodvin A, Nystrom P, Bylock A.ESTEEM Investigators. Oral ximelagatran for secondary prophylaxis after myocardial infarction:the ESTEEM randomised controlled trial. Lancet 2003; 362: 789-97. 6 Successful outcome of the Mutual Recognition Procedure for ExantaTM ( Ximelagatran )in Europe. http://www.astrazeneca.com/pressrelease ( accessed 19 July 2004 ). Competing interests: None declared |
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David A Fitzmaurice, Professor of Primary Care The University of Birmingham, B15 2TT
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Kamat appears to have been taken in by industry spin. It is interesting that UK and Ireland have denied Astra Zeneca a licence for their product pending further work. Could it be that the problem with liver function is troubling the licencing authority? The direct oral thrombin inhibitors will undoubtedly have a role in therapy in the future however it is a little early to be predicting the demise of warfarin. Whilst warfarin is still being used there will remain a role for self- testing and management, and training for patients is a vital element in the clinical efficacy of this model of care. Competing interests: I have received educational grants from Roche Diagnostics and Astra Zeneca |
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