Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Better option for some third world countries
- Jeevan P Marasinghe (7 November 2005)
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Self-management of oral anticoagulant therapy by portable coagulation monitors.
- Giuseppe Lippi, Massimo Franchini, Gian Cesare Guidi (7 November 2005)
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Warfarin and insulin; what's the difference?
- Dave Hambidge (7 November 2005)
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and oh! so much more convenient for the PATIENT!
- Julia Wyatt (7 November 2005)
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Still room for improvements?
- Ulrike Didjurgeit, Andreas Waltering, and Caroline Kleespies (14 December 2005)
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Re: Still room for improvements?
- DA Fitzmaurice (16 December 2005)
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Jeevan P Marasinghe, Medical officer 3-Premature Baby Unit,De Zoyza hospital for women ,Colombo,Sri Lanka.
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Anticoagulation therapy for various cardiac diseases has to be carefully monitored and planned due to the adverse effects of the anticoagulant drugs and effects on low drug levels manifested by thrombotic phenomena. This is a time consuming process and it needs a lot of man power.It is specially difficult for third world countries like Sri Lanka since we have a very limited number of doctors compared to developed countries to a given number in the population.Since we have a literacy rate of arround 93% in Sri Lanka, it is a workable solution to implement and can result in more awareness among patients regarding their disease state. Competing interests: None declared |
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Giuseppe Lippi, Associate Professor Ist. Chimica e Microscopia Clinica, Università di Verona, 37121 - Verona, Italy, Massimo Franchini, Gian Cesare Guidi
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The clinical investigation of Fitzmaurice and colleagues, aimed to evaluate the effectiveness of patient self management of oral anticoagulation therapy (OAT), concluded that, with appropriate training, self management is safe and reliable, improving the time spent the therapeutic range and lowering the probability of adverse hemorrhagic or thromobotic events (1). This conclusion discloses an innovative and intriguing scenario on the traditionally challenging issue of long term OAT management. Commercial availability and utilization of portable coagulation monitors (PCMs) for prothrombin time-International Normalized Ratio (PT-INR) testing has gained much popularity over the paste decade. Main advantages of PCMs include ease of use, shorter test duration, improved turnaround time and increased patient convenience. So far, several studies have investigated the analytical performances and the overall reliability of these testing devices, as alternative approaches to traditional laboratory testing. In general, the slightly lower precision of the PT-INR measured with PCMs is largely weighed against the clinical advantages (2,3). Continuous advances in applied technology and introduction of appropriate quality assessment schemes predict easy success of this new approach to the management of patients on OAT (2). Accordingly, for patients who have been appropriately trained to the use of the portable testing devices, self management by PCMs might turn out to be at least as clinically effective as the routine care provided by traditional oral anticoagulation clinics, improving patient’s convenience, optimizing resources utilization and quality, and finally improving the whole patient management. References 1. Fitzmaurice DA, Murray ET, McCahon D, Holder R, Raftery JP, Hussain S, Sandhar H, Hobbs FD. Self management of oral anticoagulation: randomised trial. BMJ 2005;331:1057. 2. Tripodi A. Prothrombin time international normalized ratio monitoring by self-testing. Curr Opin Hematol 2004;11:141-5. 3. Murray ET, Fitzmaurice DA, McCahon D. Point of care testing for INR monitoring: where are we now? Br J Haematol 2004;127:373-8. Competing interests: None declared |
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Dave Hambidge, Independent Consultant Psychiatrist Self employed
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Apart from the very obvious, there is none! Both medications require dose adjustment according to blood tests and both have become technically easy and reliable. Blood sugar testing was revolutionised 25 years or so ago, INR much more recently. The end result is that even I can do it, and have done so for over 8 years, and lived to tell the tale. This excellent paper should start to toll the death bell for Warfarin clinics. Competing interests: I self manage my INR |
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Julia Wyatt, 'justaretirednurse' NA
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I had a thalamic infarction two years ago so I have dreadful Central Pain as well as OA, and now a pacemaker. Going to the anticoag clinic became a nightmare. The discomfort of waiting for ambulance transport left me exhausted. Like Dave Hambidge I realised that INR testing was no more difficult than doing a blood sugar - though this was vehemently denied by many of the staff.With help from my family I bought a CoagucheckS, carefully read the excellent instructions and watched the DVD. The downside is that my GP told me that 'they had decided not to supervise home testing',so I have to guess that if my INR is within range I continue the same dose. So far I've remained within range. I do realise that I'm taking a risk doing this, and must get round to making contact with the local hamatogist. But it is clearly time that there is a major re-think about INR testing. I hope that this latest comprehensive paper(one of many) will encourage two things: that we can confidently allow patients to self test for INR, and as a result stop the ridiculous and expensive business of transporting patients long distances - often in considerable discomfort -to perform a test wich takes a few seconds. Competing interests: None declared |
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Ulrike Didjurgeit, Working group on structured teaching and treatment programmes DIeM-Institute for evidence based medicine, 50823 Cologne, Germany, Andreas Waltering, and Caroline Kleespies
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To the editor: Fitzmaurice et al. have found no significant differences with regard to time spent within the target range of INR in their randomised controlled trial comparing self-management of oral anticoagulation with routine care (1). Most importantly, the quality of an INR control improved in the intervention and in the control group when compared to baseline. This may point in the direction of a study effect on the quality of an INR control in the routine care group. In addition, in the intervention group patients were trained in self- management of anticoagulation based on a uniform dose adaptation scheme for all patients. In contrast, we have found major improvement in the quality of anticoagulation control in patients randomised to self- management of anticoagulation. The difference between the results of our trial (2, 3) and those of Fitzmaurice et. al. may be explained by the lack of study effect on the quality of anticoagulation control in the control group in our trial and / or a different structure of the teaching and treatment programme we used for the training of the patients in the intervention group. Our anticoagulation teaching and treatment programme (2) consists of three sessions where patients are taught to find their own optimal best algorithm for adaptation of warfarin, depending on the measured INR values. This approach resulted in short-term and long-term positive effects when compared to routine care. We have also described positive effects of structured teaching and treatment programmes in other chronic diseases like diabetes mellitus (4) and hypertension (5) based on a similar approach, where patients learn how to find their individual best algorithm for the adaptation of treatment according to their self-measured values. We suggest that future trials should compare different approaches of self- management algorithms in the investigation of self-management in chronic diseases. 1. Fitzmaurice DA, Murray ET, McCahon D, et al. Self management of oral anticoagulation: randomised trial. BMJ 2005;331:1057- 2. Sawicki PT for the working group for the study of patient self- management of oral anticoagulation. A structured teaching and self- management program for patients receiving oral anticoagulation. JAMA 1999;281:145-150 3. Sawicki PT, Gläser B, Kleespies C, et al. Long-term results of patients´ self-management of oral anticoagulation. J Clin Bas Cardiol 2003;6:59-62 4. Kronsbein P, Jörgens V, Mühlhauser I, et al. Evaluation of a structured treatment and teaching programme on non-insulin dependent diabetes. Lancet 1988;ii:1407-1411 5. Mühlhauser I, Sawicki PT, Didjurgeit U, et al. Evaluation of a structured treatment and teaching programme on hypertension in general practice. Clin Exptl Hypertension 1993;15:125-142 6. Trocha AK, Schmidtke C, Didjurgeit U, et al. Effects of intensified antihypertensive treatment in diabetic nephropathy: Mortality and morbidity results of a prospective controlled 10 years study. J Hypertens 1999;17:1497-1503 Competing interests: None declared |
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DA Fitzmaurice, Professor of Primary Care University of Birmingham, B15 2TT
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Didjurgeit and colleagues observations are not accurate. Their was never a uniform dose adjustment. Patients were given individualised algorithms which they were able to adapt empirically. In comparing outcomes between our study and Sawicki's, care is needed, as baseline care within the Sawicki group is relatively poor, an obscure measure of improvement is made, and the overall improvement as stated in the JAMA paper was not impressive.It was because of doubts about the effectiveness of self-management as described in the Sawicki paper, compared to routine care in the UK, that the SMART study was undertaken. Improvement is inherent within the UK system, and it was never likely that we would demonstrate improvment beyond this. Given the huge numbers of patients now requiring treatment however, the SMART study has demonstrated an alternative model of care, albeit a relatively expensive one. Competing interests: None declared |
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