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Advanced Cardio Services
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PT/INR Home Testing & Monitoring help and assistance for Patients and Physicians
PT/INR Home Testing & Monitoring help and assistance for Patients and Physicians

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Warfarin and Undergoing Procedures:

What to do with warfarin when a procedure is scheduled has always been a topic of much debate…  Some favor stopping anticoagulation altogether, others think that it should continue without interruption.  As with just about everything else involving warfarin, the decision should be made based on an individual patient’s risks and benefits and the procedure being performed.

The following is a list of VERY general guidelines for some common outpatient procedures.  Again, what to do with warfarin should ALWAYS be discussed with your providers.

General recommendations are often too general, but can be useful and guide us in the right direction.  ALL decisions regarding warfarin dosing should be made together with the patient, anticoagulation provider and the doctor performing the procedure—everyone needs to be in agreement and on the same page.   

written by Christine Hartig, PharmD, CACP

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Today is the First Annual World Thrombosis Day - October 13th. Please share this information with your family and friends, it could save a life no matter what the age.

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NICE recommends self-monitoring tests for people on long-term anticoagulation therapy

24 September 2014

NICE (National Institute for Health and Care Excellence) has published guidance recommending 2 technologies that enable people on long-term anticoagulation therapy to monitor their blood clotting themselves. 

The NICE diagnostics guidance on self-monitoring coagulometers supports the use of the Coaguchek XS system (Roche Diagnostics) and the InRatio2 PT/INR Monitor (Alere) as options for some adults with atrial fibrillation or heart valve disease who are on long-term anticoagulation therapy such as warfarin, and who are at higher risk of developing blood clots, to self-monitor the time it takes for their blood to clot (coagulation).

The devices monitor how quickly blood clots using a measure known as the international normalised ratio (INR). The INR enables the dose of anticoagulant to be adjusted if required. This in turn can help prevent major bleeding, heart attack or stroke that can result from an over- or under-dose of anticoagulant.

Self-monitoring can involve either self-testing (where the user performs the INR test themselves and then contacts their health professional for advice on any change to the dosage of anticoagulant that may be required) or self-managing (where the user performs the INR test themselves and then adjusts the dosage of their anticoagulant medication by following an agreed care protocol).

“The evidence shows that greater use of self-monitoring offers clinical and patient benefit and, over time, is likely to result in reductions in heart attacks and strokes caused by blood clots,” says Professor Carole Longson, NICE Health Technology Evaluation Centre Director.

“People on long-term anticoagulation need to monitor their blood regularly to make sure they are taking the right dose of their drug. Apart from the anxiety associated with waiting for the results from an anticoagulation test and in continuing normal daily activities without knowing the risk of a bleed or clot, the time and cost of attending an anticoagulation clinic can be a significant burden for people on long-term oral anticoagulation therapy and can significantly affect both their working and family life.

“Because self-monitoring provides almost instant results, self-monitoring can reduce anxiety, provide a sense of control for the patient and remove the need to frequently attend clinics or hospitals. The Committee also heard that self-monitoring allows people to visit, or act as a carer for, other family members, without having to worry about attending testing appointments.”

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Coumadin versus the New Oral Anticoagulants:

If you are reading this article, chances are that you or someone you know takes warfarin or one of the other anticoagulants to hit the market in the last few years.  One of the big questions everyone has these days is “what is the best choice?”  This is even more the case with the recent news of Pradaxa’s $650 million dollar payout to settle more than 4000 personal injury and product liability lawsuits.  So how does one decide?

Read the full article comparing the anticoagulants and make your decision here! 

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New ACS Patient Education Resource Center and Blog Posts

ACS is offering more to patients than just the convenience of Home INR testing and monitoring! Our goal is to educate patients about health conditions they may have, drugs they take, risk factors, prevention, and management of conditions and diseases. 

ACS BLOG POSTS:
Check out our blog posts written by Christine Hartig, PharmD and anticoagulation expert! Christine worked at UC San Diego as a clinical pharmacist in the Anticoagulation Clinic for 13 years. She was in charge of direct patient care and management in the anticoagulation clinic; Research and development of comprehensive educational website targeting both patients and providers; along with being a Pharmacy student and resident preceptor.

CHRISTINE'S MOST RECENT BLOG POSTS:
Where did warfarin come from?
Possible Side Effects of Warfarin
Drug Interactions with warfarin and Coumadin
Over The Counter (OTC) and Herbal Medicine Interactions with Warfarin
What is the INR?
What you need to know about Vitamin K
What is warfarin and how do I take it?
Warfarin Tablet Identification

PATIENT EDUCATION RESOURCE CENTER:
Check out our Patient Education Resource section! There you can find published PDF articles on anticoagulation therapy, links to support sites, and articles on Health Conditions written by Bianca F. Marcolino, PhD. Bianca has her PhD in Biological Sciences from UCLA and has been a long time Medical writer. 

BIANCA'S MOST RECENT HEALTH CONDITION ARTICLES:
More on the Heart and Mechanical Valves
Gastrointestinal Bleeding (GI Bleed)
All about Strokes
HyperCoaguable States: Factor V Leiden

#patienteducation   #INRtesting   #AdvancedCardioServices   #healthconditionarticles   #Coumadin  

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Where did warfarin come from?  Did you know that it has been around for nearly a century?  

The story starts just after the Great Depression in the 1920s in the Midwest.  Previously healthy cattle began dying of internal bleeding without a known cause.  Ultimately, it was discovered that the cows had been fed moldy sweet clover hay.  At any other time in history, farmers likely would not have been forced to give their livestock spoiled feed, but following the Depression, many had few resources and no alternative.  The disease became known as “sweet clover disease” and farmers were warned to avoid feeding moldy hay to their cattle as it could kill an animal within 6 weeks.  

A decade passed and there were still some farmers who didn’t believe that sweet clover disease was real as they had never had a problem.  Ed Carlson was one of these farmers--until 1933 when he lost most of his herd to internal bleeding.  Distressed and looking for answers late one night at the local university, he came across biochemist Karl Link at the University of Wisconsin (reportedly, the professor’s door was the only unlocked one).  Professor Link wasn’t initially interested, but his senior student began experimenting with a milk can full of unclotted cow’s blood that the farmer brought with him.  Timing is everything—this chance encounter between farmer and scientist triggered the evolution of oral anticoagulants.

Link and his students spent the next several years trying to isolate the compound in the moldy hay responsible for its detrimental effects.  In 1941, they finally did—it would become known as dicoumerol.  Dicoumerol is a product of a naturally occurring plant molecule called Coumarin (not Coumadin).  Coumarin is found in many plants and is responsible for the sweet smell of freshly cut grass or hay.  Coumarin itself doesn’t have anticoagulant properties—but it can be converted to the anticoagulant dicoumerol by fungus.  This explains why it was only moldy hay that caused sweet clover disease.  The funding for this endeavor was provided by the Wisconsin Alumni Research Foundation (WARF).  

In 1945, Link had the idea of using dicoumerol as a rodenticide (yes—this is where rat poison comes in), but it was much too slow to be useful for killing rats.  The professor and his students went to work to try to modify dicoumerol to change the properties.  Of all of the various derivatives, Compound 42 (on a list of ~150) showed great promise as it was very fast-acting.  It was named WARFarin after the Alumni group that continued to support Link’s research.  It hit the market in 1948 and quickly became the most commonly used rodenticide world-wide.  

After that, the transition to therapeutic use in humans under the brand name Coumadin was fast. In 1955 it was used to treat President Eisenhower after a heart attack and from there, gained wide-spread acceptance as a useful and life-saving medication (and not just rat poison).  Management and monitoring proved to be quite challenging for many decades until the discovery of the role of vitamin K in the mid-70’s and the development of the INR in the early-80’s.  

Warfarin, for now, continues to be the most widely-used anticoagulant in the world. With the advent of weekly home PT/INR testing, using the CoaguChek XS meter, Coumadin became much easier to manage and safer to use. After all of these years it still appears that closely monitored Coumadin therapy is the safest anticoagulation therapy to date. Will the development of the new group of oral anticoagulants push warfarin out of regular use and into the history books?  Will it still be around in another century?  Only time will tell…

For more information about Coumadin and INR testing visit 

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POSSIBLE SIDE EFFECTS OF WARFARIN

If you are taking warfarin, you already know that it can save your life.  But, as with any medication, there are side effects and complications that you need to be aware of. Taking warfarin exactly as prescribed and following your provider’s instructions for dosing and INR checks are the most important things you can do to reduce your risk of a warfarin-related problem.

The most common complication of taking warfarin is bleeding—this is because we are slowing down the clotting process in your blood to prevent abnormal clotting.  In order to lower your risk of unexpected or significant bleeding, your INR should be checked frequently and your warfarin dose adjusted if the INR is too high.  

It is possible that you will experience some minor bleeding… even while your INR is within the target range.  Most people who take warfarin will notice one or more of these effects, and they are not generally considered dangerous (but should still be reported to your provider).  
Some examples of MINOR bleeding include:

• Gums bleeding when you brush your teeth—though if it happens frequently or suddenly, you should see your dentist.
• Occasional minor nosebleeds.
• Easy bruising.
• Menstrual bleeding that is heavier than usual.
• Bleeding after a minor cut that takes longer to stop than before you took warfarin.

MAJOR bleeding is an infrequent but serious complication with all anticoagulants.  The risk of dangerous bleeding goes up if you take additional blood thinners, such as aspirin. You should immediately call your anticoagulation provider or go to the emergency room if you experience any of the following:

• Changes in the color of your urine or stool
   o Red or brown urine
   o Red or black/tarry stools
• Vomit that is red or looks like coffee grounds
• Coughing up red-tinged secretions
• Severe and/or sudden headache or stomachache
• Excessive and uncontrollable bleeding from the gums or nose
• Excessive and unmanageable menstrual bleeding
• Bruises that appear with no explanation in unusual places

Most other side effects of warfarin are very rare and many tend to occur shortly after starting warfarin. Your doctor has prescribed warfarin because he/she has decided that the benefits of this medicine outweigh the risk of these possible side effects. These include:

• Rash or hypersensitivity (to the active ingredient or a dye/filler used to make the tablet)
• Tissue necrosis (<0.1% and develops within a few days of starting therapy)
• Cholesterol embolus (also known as “purple toe syndrome” results from the release of small deposits of cholesterol breaking loose and usually occurs 3-8 weeks after starting therapy)
• Gastrointestinal disorders (nausea, vomiting, diarrhea, taste aversion)
• Feeling cold/having chills
• Hair loss

Testing your INR frequently is the best preventative measure to ensure you are within your safe therapeutic range and avoid experiencing the serious side effects of warfarin or Coumadin. 

#ACS#warfarin#sideeffects#INRtesting#CoaguChekXS 

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Warfarin Home Monitoring Achieves Excellent INR Control – A Review of the 2014 STABLE Study

Weekly INR self-testing is an accurate and effective way to manage warfarin and Coumadin therapy, suggested new research. While this is not the first study to find that patients who partake in home monitoring spend more time within their “safe therapeutic range” and have less complications with their anticoagulation therapy, it is the largest retrospective study of real-world self testers and the first to compare weekly INR testing to variable testing. 

Overall, the clinical evidence from the study involving 29,457 patients followed over 2.5 years demonstrated that more frequent testing improves patient safety and decreases the risk of major thomboembolic and bleeding events. Patients testing their INR weekly achieved a significantly greater TTR (Time in Therapeutic Range) of 74% vs. 68.9% for patients self testing every 2-4 weeks. The study also stated that “Weekly testers experienced significantly fewer critical values (INR <1.5 or >5.0) than did variable testers”.

Understanding what’s considered good TTR in the real-world is important in grasping the importance of these findings, according to Dr. Ansell. “Clinical trials have established that 65% TTR is considered acceptable,” he explained. “Unfortunately, most patients on warfarin management hover around 55%. So the outcome here is outstanding.”

Patients prescribed for PST (Patient Self Testing) must be reliable to report their test results, and willing and able to test their INR with a monitor at home with a simple finger stick. Their physician submits a prescription form to an IDTF (Independent Diagnostic Testing Facility) for the service and insurance is verified. Patients then must undergo a FDA and Medicare required face-to-face training on how to utilize the meter and report test results. Physicians are then sent all INR results in order to manage the patient’s Coumadin therapy.

In all age groups involved in the study, patients testing weekly outperformed patients testing every 2-4 weeks. Additionally, the study found that patients 75 years and older that tested weekly had a mean TTR of more than 73%. The researchers stated that the results of self-testing for the elderly are significant as they are often at the highest risk of bleeding during Coumadin therapy. 

The study also brought to light the flawed comparison of trials performed by the drug makers of the new anticoagulants, Eliquis, Xarelto, and Pradaxa. Results from the STABLE Study noted that even patients who tested their INRs the least frequently performed significantly better than the top-performing patients treated with warfarin in trials involving the new oral anticoagulants. Thus if patients in the new anticoagulant trials taking Pradaxa, Xarelto, or Eliquis were compared to any of the self testing groups from the STABLE Study they would have found warfarin coupled with self INR testing to be a superior and safer method of anticoagulation therapy for patients in all circumstances.

In the United States approximately 3 million people are on warfarin, but only about 120,000 people test their INR at home, according to Dr. Ansell. He said the slow growth of self-testing could be due to a lack of physician awareness, their belief that patients can not test properly on their own, or that physicians’ may perceive that self-testing is inaccurate. This study showed otherwise. “We demonstrated that the average patient on warfarin can monitor their INRs at home, and do it very well,” he said. “We’ve shown that self-testing is a reasonable and feasible means of practice.”

The study was published online in the American Journal of Managed Care and the full blog and PDF article can be viewed at www.AdvancedCardioServices.com.

#Coumadin   #INRHomeTesting   #warfarin   #PatientSelfTesting   #AdvancedCardioServices   #CoaguChek   #STABLEstudy  

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Home Monitoring of Coumadin and warfarin Comes of Age

In an article written by Harvard Medical professor, Thomas H. Lee M.D., on July 9th 2013 he discusses the annoyances of living on Coumadin therapy and how home INR testing works to alleviate these issues. This blood thinner prevents strokes and complications from blood clots for people with issues like Mechanical Heart Valves, atrial fibrillation, pulmonary embolism, and DVTs. With more studies being published on the benefits of weekly home anticoagulation testing and monitoring more insurances are now covering the service, making it more readily available to the masses making management of warfarin therapy a much more convenient and safer option to testing at the doctor’s office or lab.

Home testing will replace inconvenient trips to the doctor’s office of Coumadin clinic allowing patients to test from the comfort of their home. The meters are similar in size to a glucose meter, give accurate INR results in just a few minutes from a finger stick. The physician or pharmacist uses the INR in determining whether you have too much or too little anticoagulating activity. This allows patients to know right away if they are within their prescribed “safe therapeutic rage”. If the INR is too high it puts you at risk of bleeding complications and too low puts you at risk of having a blood clot form.

With a technology that has been around for years and found in most doctors’ office, it leaves patients wondering why they need to drive to the doctor’s office, pay a copay, pay for parking, wait in the waiting room with other sick people, and then drive back to work or home just for a finger stick that they could do at home.

The reason that insurances such as Medicare, Blue Cross, Blue Shield, Humana, and others are now covering Home INR testing is because people who use the home meters to test at home appear to spend more time within their “safe therapeutic range” because they are able to test their INR more frequently. This allows their physician to more closely monitor their Coumadin therapy which results in far less complications associated with the drug. People who use the devices tend to be happier and have a general confidence that they are in control of their medical treatments.

With insurances now covering home monitors, saving people time, money, and simply keeping them safer than they would be otherwise it is the clear INR monitoring option of choice for people living on long term warfarin therapy. Many people can now look forward to spending more time at home with their families and less time making the arduous trip to the doctor’s office or anticoagulation clinic.

View ACS' blog and link to the entire article written by Dr Thomas H. Lee.

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Drug Interactions with Warfarin

Despite its effectiveness, treatment with warfarin can be complicated as many commonly used medications interact.  However, interaction doesn’t always mean incompatibility:  Often the interaction is predictable and the adjustment to the warfarin dose can be anticipated.  At other times, the influence on the INR is more variable and the INR will need to be monitored more frequently so that adjustments can be made to keep the INR in range.  

Always make sure each of your doctors knows about all of your medicines from other doctors and double check every medicine change with your anticoagulation provider.

To view a list of the more commonly seen interactions and the potential influence on the INR, visit www.AdvancedCardioServices.com and visit the blog.

These are all general guidelines and possible drug interaction situations with warfarin. All dosage adjustments should be made by your physician or pharmacist that is managing your warfarin therapy. The best practice while on warfarin therapy is weekly home INR testing in order to catch any INR rises or falls ahead of time as your medications, diet, or life changes.
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