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Follow-Up of a Home Care Patient: Warfarin Usage

Year 2016, Volume: 30 Issue: 2, 89 - 94, 21.10.2016

Abstract

Warfarin is
commonly used drug; however its dosage is affected
by plenty of food and drugs. As it can cause bleeding, its follow-up is important. Patients are monitored by International Normalized Ratio (INR), standard value of the prothrombin
time, and the target values vary 2-3.5 for
different diagnosis.

A 76-year-old female patient had a cerebrovascular accident after a cholecystectomy operation. As a sequel she had loss of strength in her right foot. Her caregivers, 77-year-old husband and a professional caregiver, applied to home care services (HCSs).





Ecchymosis was seen in her body in her physical examination while vital signs were normal. Additionally decubitus ulcers on her gluteal
region, loss of strength at her right foot was determined. She had been in this
condition for 5-6 months and the ecchymosis was attributed to impacts during caring. She was referred
to emergency department because of bleeding
risk. In her first evaluation INR: 6.6, however no bleeding
was not detected except for widespread ecchymosis. Warfarin was stopped
for 3 days and the treatment regimen was planned
again. After 12 days, control INR: 2.96. Family
physicians'
informing caregivers during
follow-up 
of
 home-care  patients,  about
 patients'  drugs,  drug-drug
 interactions,  especially drug-food
interactions regularly
is important.




References

  • Referans1 Türk Hematoloji Derneği, Kumadin Kullanım Rehberi 2010. http://www.thd.org.tr/thd_halk/?sayfa=kkr (Erişim Tarihi 26 Ağustos 2014).
  • Referans2 Hull RD, Therapeutic use of warfarin and other vitamin K antagonists, http://www.uptodate.com/contents/therapeutic-use-of- warfarin-and-other-vitamin-k- antagonists?source=search_result&search=warfarin&sele cted (Erişim Tarihi 29 Haziran 2015).
  • Referans3 Eroğlu SE, A.Denizbaşı A, Özpolat Ç, et al. The Investigation of the Relation Between INR Levels and Risk of Complication in Patients with a History oföWarfarin use, Marmara Medical Journal, 2012; 25; 3, 138-142.
  • Referans4 Wysowski DK, Nourjah P, Swartz L. Bleeding complications with warfarin use: a prevalent adverse effect resulting in regulatory action. Arch Intern Med 2007; 167:1414-1419.
  • Referans5 Ansell J, Hirsh J, Hylek E, Jacobson A, Crowther M, Palareti G; American College of Chest Physicians. Pharmacology and management of the vitamin K antagonists: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008; 133:160S- 198S.
  • Referans6 Batke-Hastings S, Carman TL. Sublingual administration of warfarin: a novel form of delivery. Vasc Med 2008; 13:123-126.
  • Referans7 Zhao HJ, Zheng ZT, Wang ZH, et al. "Triple therapy" rather than "triple threat": a meta-analysis of the two antithrombotic regimens after stent implantation in patients receiving long-term oral anticoagulant treatment. Chest 2011; 139:260-270.
  • Referans8 Nieto JA, Solano R, Ruiz-Ribó MD, et al. Fatal bleeding in patients receiving anticoagulant therapy for venous thromboembolism: findings from the RIETE registry. J Thromb Haemost 2010; 8:1216-1222.
  • Referans9 Ruíz-Giménez N, Suárez C, González R, et al. Predictive variables for major bleeding events in patients presenting with documented acute venous thromboembolism. Findings from the RIETE Registry. Thromb Haemost 2008; 100:26-31.
  • Referans10 Anand S, Yusuf S, Xie C, et al. Warfarin Antiplatelet Vascular Evaluation Trial Investigators. Oral anticoagulant and antiplatelet therapy and peripheral arterial disease. N Engl J Med 2007; 357:217-227.
  • Referans11 Gage BF, Yan Y, Milligan PE, et al. Clinical classification schemes for predicting hemorrhage: results from the National Registry of Atrial Fibrillation (NRAF). Am Heart J 2006; 151:713-719.
  • Referans12 Douketis JD, Arneklev K, Goldhaber SZ, Spandorfer J, Halperin F, Horrow J. Comparison of bleeding in patients with nonvalvular atrial fibrillation treated with ximelagatran or warfarin: assessment of incidence, case- fatality rate, time course and sites of bleeding, and risk factors for bleeding. Arch Intern Med 2006; 166:853-859. Referans13 Shireman TI, Howard PA, Kresowik TF, Ellerbeck EF. Combined anticoagulant-antiplatelet use and major bleeding events in elderly atrial fibrillation patients. Stroke 2004; 35:2362-2367.
  • Referans14 Wells PS, Forgie MA, Simms M, et al. The outpatient bleeding risk index: validation of a tool for predicting bleeding rates in patients treated for deep venous thrombosis and pulmonary embolism. Arch Intern Med 2003; 163:917-920.
  • Referans15 van Walraven C, Hart RG, Singer DE, et al. Oral anticoagulants vs aspirin in nonvalvular atrial fibrillation: an individual patient meta-analysis. JAMA 2002; 288:2441-2448.,
  • Referans16 Odén A, Fahlén M. Oral anticoagulation and risk of death: a medical record linkage study. BMJ 2002; 325:1073-1075.
  • Referans17 Veeger NJ, Piersma-Wichers M, Tijssen JG, Hillege HL, van der Meer J. Individual time within target range in patients treated with vitamin K antagonists: main determinant of quality of anticoagulation and predictor of clinical outcome. A retrospective study of 2300 consecutive patients with venous thromboembolism. Br J Haematol 2005; 128:513-519.
  • Referans18 Limdi NA, Beasley TM, Baird MF, et al. Kidney function influences warfarin responsiveness and hemorrhagic complications. J Am Soc Nephrol 2009; 20:912-921.
  • Referans19 Fitzmaurice DA, Blann AD, Lip GY. Bleeding risks of antithrombotic therapy. BMJ 2002; 325:828-831.
  • Referans20 Schelleman H, Bilker WB, Brensinger CM, Wan F, Yang YX, Hennessy S. Fibrate/Statin initiation in warfarin users and gastrointestinal bleeding risk. Am J Med 2010; 123:151-157.
  • Referans21 Delaney JA, Opatrny L, Brophy JM, Suissa S. Drug drug interactions between antithrombotic medications and the risk of gastrointestinal bleeding. CMAJ 2007; 177:347-351.
  • Referans22 http://www.uptodate.com/contents/warfarin-coumadin- beyond-the-basics? (Erişim Tarihi 26 Ağustos2014).
  • Referans23 Oake N, Jennings A, Forster AJ, Fergusson D, Doucette S, van Walraven C. Anticoagulation intensity and outcomes among patients prescribed oral anticoagulant therapy: a systematic review and meta-analysis. CMAJ 2008; 179:235-244.
  • Referans24 Torn M, Cannegieter SC, Bollen WL, van der Meer FJ, van der Wall EE, Rosendaal FR. Optimal level of oralanticoagulant therapy for the prevention of arterial thrombosis in patients with mechanical heart valve prostheses, atrial fibrillation, or myocardial infarction: a prospective study of 4202 patients. Arch Intern Med 2009; 169:1203-1209.
  • Referans25 Franco V, Polanczyk CA, Clausell N, Rohde LE. Role of dietary vitamin K intake in chronic oral anticoagulation: prospective evidence from observational and randomized protocols. Am J Med 2004; 116:651-656.
  • Referans26 Schurgers LJ, Shearer MJ, Hamulyák K, Stöcklin E, Vermeer C. Effect of vitamin K intake on the stability of oral anticoagulant treatment: dose-response relationships in healthy subjects. Blood 2004; 104:2682-2689.
  • Referans27 Kurnik D, Loebstein R, Rabinovitz H, Austerweil N, Halkin H, Almog S. Over-the-counter vitamin K1- containing multivitamin supplements disrupt warfarin anticoagulation in vitamin K1-depleted patients. A prospective, controlled trial. Thromb Haemost 2004; 92:1018-1024.
  • Referans28 Couris R, Tataronis G, McCloskey W, et al. Dietary vitamin K variability affects International Normalized Ratio (INR) coagulation indices. Int J Vitam Nutr Res 2006; 76:65-74. Referans29 Khan T, Wynne H, Wood P, et al. Dietary vitamin K influences intra-individual variability in anticoagulant response to warfarin. Br J Haematol 2004; 124:348-354.
  • Referans30 Rohde LE, de Assis MC, Rabelo ER. Dietary vitamin K intake and anticoagulation in elderly patients. Curr Opin Clin Nutr Metab Care 2007; 10:1-5.
  • Referans31 de Assis MC, Rabelo ER, Avila CW, Polanczyk CA, Rohde LE. Improved oral anticoagulation after a dietary vitamin k-guided strategy: a randomized controlled trial. Circulation 2009; 120:1115-1122.
  • Referans32 Fanikos J, Grasso-Correnti N, Shah R, Kucher N, Goldhaber SZ. Major bleeding complications in a specialized anticoagulation service. Am J Cardiol 2005; 4; 595-598.
  • Referans33 Gando S, Nanzaki S, Sasaki S, Kemmotsu O. Significant correlations between tissue factor and thrombin markers in trauma and septic patients with disseminated intravascular coagulation. Thromb Haemost 1998; 79; 1111-1115.

Evde bakım hastasının izlemi: Varfarin kullanımı

Year 2016, Volume: 30 Issue: 2, 89 - 94, 21.10.2016

Abstract

Varfarin sık kullanılan ancak kullanım dozu pek çok ilaç ve yiyeceklerde etkilenen bir ilaçtır. Kanamaya neden olabileceğinden izlemi önemlidir. Hastalar Protrombin Zamanı
standart değeri olan INR (International Normalized Ratio) ile izlenmekte ve
farklı tanılarda hedef değerler
2-3,5 arasında değişmektedir.



76 yaşındaki kadın hasta kolesistektomi operasyonu sonrası serebrovasküler olay geçirmiştir. Hastanın sekel olarak sağ ayağında
kuvvet kaybı mevcuttur. Hastaya bakan 77 yaşındaki eşi ve profesyonel bakıcısı evde sağlık hizmetleri (ESH) birimine başvurmuştur.



Vital bulguları normal olan hastanın vücudunda ekimozlar görüldü. Ayrıca gluteal bölgesinde bası yaraları, sağ ayakta kuvvet kaybı belirlendi. Hasta 5-6 aydır bu durumda ve morlukları bakım sırasındaki çarpmalara
bağlanmış. Kanama riski nedeniyle acil servise
sevk edildi. İlk değerlendirmesinde INR: 6,6 olup yaygın
ekimoz dışında kanama tespit edilmedi. Varfarin üç gün kesildi
ve tedavi rejimi yeniden
düzenlendi.
Oniki gün
sonra bakılan kontrol INR: 2,96’ydi.



Aile hekimlerinin evde bakım hastalarının izlemlerinde bakımverenleri hastaların ilaçları, ilaç-ilaç etkileşimleri, özellikle ilaç-gıda etkileşimi konularında düzenli bilgilendirmesi önemlidir.




References

  • Referans1 Türk Hematoloji Derneği, Kumadin Kullanım Rehberi 2010. http://www.thd.org.tr/thd_halk/?sayfa=kkr (Erişim Tarihi 26 Ağustos 2014).
  • Referans2 Hull RD, Therapeutic use of warfarin and other vitamin K antagonists, http://www.uptodate.com/contents/therapeutic-use-of- warfarin-and-other-vitamin-k- antagonists?source=search_result&search=warfarin&sele cted (Erişim Tarihi 29 Haziran 2015).
  • Referans3 Eroğlu SE, A.Denizbaşı A, Özpolat Ç, et al. The Investigation of the Relation Between INR Levels and Risk of Complication in Patients with a History oföWarfarin use, Marmara Medical Journal, 2012; 25; 3, 138-142.
  • Referans4 Wysowski DK, Nourjah P, Swartz L. Bleeding complications with warfarin use: a prevalent adverse effect resulting in regulatory action. Arch Intern Med 2007; 167:1414-1419.
  • Referans5 Ansell J, Hirsh J, Hylek E, Jacobson A, Crowther M, Palareti G; American College of Chest Physicians. Pharmacology and management of the vitamin K antagonists: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008; 133:160S- 198S.
  • Referans6 Batke-Hastings S, Carman TL. Sublingual administration of warfarin: a novel form of delivery. Vasc Med 2008; 13:123-126.
  • Referans7 Zhao HJ, Zheng ZT, Wang ZH, et al. "Triple therapy" rather than "triple threat": a meta-analysis of the two antithrombotic regimens after stent implantation in patients receiving long-term oral anticoagulant treatment. Chest 2011; 139:260-270.
  • Referans8 Nieto JA, Solano R, Ruiz-Ribó MD, et al. Fatal bleeding in patients receiving anticoagulant therapy for venous thromboembolism: findings from the RIETE registry. J Thromb Haemost 2010; 8:1216-1222.
  • Referans9 Ruíz-Giménez N, Suárez C, González R, et al. Predictive variables for major bleeding events in patients presenting with documented acute venous thromboembolism. Findings from the RIETE Registry. Thromb Haemost 2008; 100:26-31.
  • Referans10 Anand S, Yusuf S, Xie C, et al. Warfarin Antiplatelet Vascular Evaluation Trial Investigators. Oral anticoagulant and antiplatelet therapy and peripheral arterial disease. N Engl J Med 2007; 357:217-227.
  • Referans11 Gage BF, Yan Y, Milligan PE, et al. Clinical classification schemes for predicting hemorrhage: results from the National Registry of Atrial Fibrillation (NRAF). Am Heart J 2006; 151:713-719.
  • Referans12 Douketis JD, Arneklev K, Goldhaber SZ, Spandorfer J, Halperin F, Horrow J. Comparison of bleeding in patients with nonvalvular atrial fibrillation treated with ximelagatran or warfarin: assessment of incidence, case- fatality rate, time course and sites of bleeding, and risk factors for bleeding. Arch Intern Med 2006; 166:853-859. Referans13 Shireman TI, Howard PA, Kresowik TF, Ellerbeck EF. Combined anticoagulant-antiplatelet use and major bleeding events in elderly atrial fibrillation patients. Stroke 2004; 35:2362-2367.
  • Referans14 Wells PS, Forgie MA, Simms M, et al. The outpatient bleeding risk index: validation of a tool for predicting bleeding rates in patients treated for deep venous thrombosis and pulmonary embolism. Arch Intern Med 2003; 163:917-920.
  • Referans15 van Walraven C, Hart RG, Singer DE, et al. Oral anticoagulants vs aspirin in nonvalvular atrial fibrillation: an individual patient meta-analysis. JAMA 2002; 288:2441-2448.,
  • Referans16 Odén A, Fahlén M. Oral anticoagulation and risk of death: a medical record linkage study. BMJ 2002; 325:1073-1075.
  • Referans17 Veeger NJ, Piersma-Wichers M, Tijssen JG, Hillege HL, van der Meer J. Individual time within target range in patients treated with vitamin K antagonists: main determinant of quality of anticoagulation and predictor of clinical outcome. A retrospective study of 2300 consecutive patients with venous thromboembolism. Br J Haematol 2005; 128:513-519.
  • Referans18 Limdi NA, Beasley TM, Baird MF, et al. Kidney function influences warfarin responsiveness and hemorrhagic complications. J Am Soc Nephrol 2009; 20:912-921.
  • Referans19 Fitzmaurice DA, Blann AD, Lip GY. Bleeding risks of antithrombotic therapy. BMJ 2002; 325:828-831.
  • Referans20 Schelleman H, Bilker WB, Brensinger CM, Wan F, Yang YX, Hennessy S. Fibrate/Statin initiation in warfarin users and gastrointestinal bleeding risk. Am J Med 2010; 123:151-157.
  • Referans21 Delaney JA, Opatrny L, Brophy JM, Suissa S. Drug drug interactions between antithrombotic medications and the risk of gastrointestinal bleeding. CMAJ 2007; 177:347-351.
  • Referans22 http://www.uptodate.com/contents/warfarin-coumadin- beyond-the-basics? (Erişim Tarihi 26 Ağustos2014).
  • Referans23 Oake N, Jennings A, Forster AJ, Fergusson D, Doucette S, van Walraven C. Anticoagulation intensity and outcomes among patients prescribed oral anticoagulant therapy: a systematic review and meta-analysis. CMAJ 2008; 179:235-244.
  • Referans24 Torn M, Cannegieter SC, Bollen WL, van der Meer FJ, van der Wall EE, Rosendaal FR. Optimal level of oralanticoagulant therapy for the prevention of arterial thrombosis in patients with mechanical heart valve prostheses, atrial fibrillation, or myocardial infarction: a prospective study of 4202 patients. Arch Intern Med 2009; 169:1203-1209.
  • Referans25 Franco V, Polanczyk CA, Clausell N, Rohde LE. Role of dietary vitamin K intake in chronic oral anticoagulation: prospective evidence from observational and randomized protocols. Am J Med 2004; 116:651-656.
  • Referans26 Schurgers LJ, Shearer MJ, Hamulyák K, Stöcklin E, Vermeer C. Effect of vitamin K intake on the stability of oral anticoagulant treatment: dose-response relationships in healthy subjects. Blood 2004; 104:2682-2689.
  • Referans27 Kurnik D, Loebstein R, Rabinovitz H, Austerweil N, Halkin H, Almog S. Over-the-counter vitamin K1- containing multivitamin supplements disrupt warfarin anticoagulation in vitamin K1-depleted patients. A prospective, controlled trial. Thromb Haemost 2004; 92:1018-1024.
  • Referans28 Couris R, Tataronis G, McCloskey W, et al. Dietary vitamin K variability affects International Normalized Ratio (INR) coagulation indices. Int J Vitam Nutr Res 2006; 76:65-74. Referans29 Khan T, Wynne H, Wood P, et al. Dietary vitamin K influences intra-individual variability in anticoagulant response to warfarin. Br J Haematol 2004; 124:348-354.
  • Referans30 Rohde LE, de Assis MC, Rabelo ER. Dietary vitamin K intake and anticoagulation in elderly patients. Curr Opin Clin Nutr Metab Care 2007; 10:1-5.
  • Referans31 de Assis MC, Rabelo ER, Avila CW, Polanczyk CA, Rohde LE. Improved oral anticoagulation after a dietary vitamin k-guided strategy: a randomized controlled trial. Circulation 2009; 120:1115-1122.
  • Referans32 Fanikos J, Grasso-Correnti N, Shah R, Kucher N, Goldhaber SZ. Major bleeding complications in a specialized anticoagulation service. Am J Cardiol 2005; 4; 595-598.
  • Referans33 Gando S, Nanzaki S, Sasaki S, Kemmotsu O. Significant correlations between tissue factor and thrombin markers in trauma and septic patients with disseminated intravascular coagulation. Thromb Haemost 1998; 79; 1111-1115.
There are 31 citations in total.

Details

Journal Section Articles
Authors

Muhteber Çolak This is me

Özden Gökdemir This is me

Ülkü Bulut This is me

Mehtep Kartal

Publication Date October 21, 2016
Submission Date June 29, 2015
Published in Issue Year 2016 Volume: 30 Issue: 2

Cite

Vancouver Çolak M, Gökdemir Ö, Bulut Ü, Kartal M. Evde bakım hastasının izlemi: Varfarin kullanımı. J DEU Med. 2016;30(2):89-94.