WARFARİN KULLANIMINA BAĞLI YÜKSEK INR DÜZEYİ İLE BAŞVURAN HASTALARIN DEĞERLENDİRİLMESİ: TANIMLAYICI BİR ÇALIŞMA

Year 2020, , 224 - 230, 25.06.2020

Elçin Katı , İrfan Şencan , Duygu Ayhan Başer , İzzet Fidancı , İsmail Kasım , Rabia Kahveci , Adem Özkara

https://doi.org/10.16899/jcm.734137

Abstract

Amaç: Bu çalışma ile warfarin tedavisi alıp hastanemize yüksek INR değerleri ile başvuran hastaların demografik analizlerini yapmayı, mortaliteye etki eden nedenleri saptamayı ve birinci basamaktan yararlanma durumlarını belirlemeyi amaçladık.
Gereç ve Yöntem: Herhangi bir nedenle warfarin tedavisi alan, INR değeri 4'ün üzerinde olan ve komplikasyon yaşayan 187 hasta çalışmamıza dahil edildi. Hastaların hastane epikrizlerinden hastane başvuru nedeni, hangi kliniğe başvurduğu, INR değerleri, komorbid hastalık varlığı, kan transfüzyonu ihtiyacı, tedavi sonrası sağlık durumu, warfarin endikasyonu, warfarin başlayan klinik retrospektif olarak değerlendirildi. Taburculuk durumu, warfarin kullanma süresi, takip sıklığı, birinci basamağa başvuru durumu, doz değişikliklerini hangi kliniğin yaptığı, eğitim durumu telefondan öğrenildi.
Bulgular: En sık hastaneye başvuru sebepleri kanama (%22,4), dispne (%18,2), ve kusma/bulantı (%9,6) olarak belirlendi. Hastaların %34,2'sinin INR değeri 10'un üzerindeydi. En sık warfarin başlama endikasyonu AF idi. Mortaliteye etki eden prediktörler göğüs ağrısı (p:0,012) ve hematemaz (p:0,033) olarak değerlendirildi. Birinci basamağa doz değişimi için başvuran hasta oranı %12,3idi. Hastaların takipleri en sık olarak kardiyoloji, evde sağlık hizmetleri, kardiyovasküler cerrahi ve nöroloji tarafından yapılmaktaydı (sırasıyla; 16%,6.4%,5.9%,4.3%). Warfarin eğitimi %36,8idi.
Sonuç: Warfarin sık takip gerektiren ve komplikasyonları mortal olan bir ilaç olduğu için hasta eğitimi çok önemlidir ve hastaların en kolay ulaşabilecekleri sağlık hizmeti olan birinci basamak sağlık hizmetlerini kullanmaları yönünde teşvik edilmesi gerekmektedir.

Keywords

Kanama, INR, Mortalite, Birinci basamak sağlık hizmetleri, Warfarin

Evaluation Of The Inpatients Who Apply With High INR-Level Due To Warfarine Use- A Retrospective Descriptive Study

Abstract

Objective: In this study, we searcheddemographic analysis of complications of patients who took warfarin treatment andadmitted to our hospital with high INR levels and factors affecting mortality.
Material and Method: All patients who were admitted to our hospital for any reason, who had at least 4 INR and received warfarin treatment were included in the study. The studies were analyzed retrospectively. The hospitalization epicrisis of 187 patients was evaluated. Questions were asked about duration of warfarin use, follow-up frequency, primary health care status, changes in the floor made by the clinic, and the use of warfarin data.
Results: The study population consisted of 87 women and 100 men. The mean age of the patients was 64.1 ± 17.6 years. The most common hospitalization complaints in the whole population were bleeding (22.4%), dyspnea (18.2%), confusion (17.1%) and nausea / vomiting (9.6%). INR level was above 10 in 34.2% of the patients. The highest indication of warfarin use was AF. Hypertension was the highest comorbidity. The predictors of mortality were chest pain (HR = 3.808; p = 0.012) and hemathesis (HR = 3.688; p = 0.033), respectively. The number of patients admitted to primary care for warfarin was 23 (12.3%). Patients were followed up in cardiology, home health care, cardiovascular surgery and neurology (16%, 6.4%, 5.9%, 4.3%, respectively). The rate of people who received warfarin training was 36.8%.
Conclusion: Although warfarin is a drug that should be monitored frequently, the follow-up frequency of patients is very low.

Keywords

Bleeding, INR, Mortality, Primary Health Care, Warfarine

References

• 1. Fareed J, Hoppensteadt DA, Bick RL. An update on heparins at thebeginning of the new millennium. Semin Thromb Hemost 2000; 26(1): 5-21. 2. Hoffman M, Monroe DM. 3rd, A cell-based model of hemostasis. ThrombHaemost 2001; 85(6): 958-65. 3. Campbell HA, Link KP. Studies on the hemorrhagic sweet clover disease:IV.Theisolation and crystallization of the hemorrhagic agent. J Biol C 1941; 138: 21-33. 4. Landefeld CS, Goldman L. Major bleeding in outpatients treated withwarfarin: incidence and prediction by factors known at the start of outpatienttherapy. Am J Med 1989; 87(2): 144-52. 5. Landefeld CS, Rosenblatt MW, Goldman L. Bleeding in outpatientstreated with warfarin: relation to the prothrombin time and importantremediable lesions. Am J Med 1989; 87(2): 153-9. 6. Horton JD, Bushwick BM. Warfarin therapy: evolving strategies inanticoagulation. Am Fam Physician 1999; 59(3): 635-46. 7.Schulman S. et al. The duration of oral anticoagulant therapy after a secondepisode of venous thromboembolism. The Duration of Anticoagulation TrialStudy Group. N Engl J Med 1997; 336(6): 393-8. 8. Witt DM, et al. Outcomes and predictors of very stable INR control duringchronic anticoagulation therapy. Blood 2009; 114(5): 952-6. 9. Landefeld CS, Beyth RJ. Anticoagulant-related bleeding: clinicalepidemiology, prediction, and prevention. Am J Med 1993; 95(3): 315-28. 10. Anthony CJ, Ackroyd-Stolarz KS, et al. Intensity of anticoagulation withwarfarin and risk of adverse in patients presenting to the emergencydepartment. Ann Pharmacother 2011; 45(7-8): 881-7. 11. Eroğlu S, Denizbaşı AA, Özpolat Ç, Akoğlu H, Onur ÖO, Ünal EA.Varfarin Kullanım Öyküsü Olan Hastalarda, INR Değerleriyle Komplikasyon Gelişim Risk İlişkisinin Ortaya Konması. Marmara Medical Journal 2012; 25: 138-42. 12. Dursun R. Warfarin kullanan hastalarda meydana gelen komplikasyonların demografik analizi ve mortalite üzerine etkili faktörler Dicle Üniversitesi Tıp Fakültesi Acil Tıp A.D, 2010. Uzmanlık Tezi. 13. Wallvik J, et al. Bleeding complications during warfarin treatment in primary healthcare centres compared with anticoagulation clinics. Scand J Prim Health Care 2007; 25(2): 123-8. 14. Ekiz M. Warfarin kullanımına bağlı kanama nedeniyle acil servise başvuran hastaların geriye dönük olarak değerlendirilmesi. 19 mayıs üniversitesi Acil tıp ABD, 2012. Uzmanlık tezi. 15. Ebell MH. Predicting the risk of bleeding in patients taking warfarin. Am Fam Physician 2010. 81(6): 780 16. Shireman TI, et al. Development of a contemporary bleeding risk model for elderly warfarin recipients. Chest 2006; 130(5): 1390-6. 17.Lindh JD, et al. Incidence and predictors of severe bleeding during warfarin treatment. J Thromb Thrombolysis 2008. 25(2): 151-9. 18.Bussey HI, et al. The safety and effectiveness of long-term warfarin therapy in an anticoagulation clinic. Pharmacotherapy 1989; 9(4): 214-9. 19. Mcmahon D. Risk Of Major Hemorrhage For Outpatients Treatment With Warfarin. Journal Gen Intern Med 1998; 13: 311-6. 20.Palareti G, et al. Bleeding complications of oral anticoagulant treatment: an inception-cohort, prospective collaborative study (ISCOAT). Italian Study on Complications of Oral Anticoagulant Therapy. Lancet 1996; 348(9025): 423- 8. 21. Fanikos J, et al. Major bleeding complications in a specialized anticoagulation service. Am J Cardiol 2005; 96(4): 595-8. 22.Koo S, Kucher N, Nguyen PL, Fanikos J, Marks PW, Goldhaber SZ.The effect of excessive anticoagulation on mortality and morbidity in hospitalized patients with anticoagulant-related major hemorrhage. Arch Intern Med 2004; 164(14): 1557-60. 23. Makris M, Watson HG. The management of coumarin-induced overanticoagulation Annotation. Br J Haematol 2001; 114(2): 271-80. 24. Landefeld CS, Goldman L. Major bleeding in outpatients treated with warfarin: incidence and prediction by factors known at the start of outpatient therapy. Am J Med 1989; 87(2): 144-52. 25. Levine MN, et al. Hemorrhagic complications of anticoagulant treatment: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004; 126(3): 287-310. 26. Ridker PM, et al. Long-term, low-intensity warfarin therapy for the prevention of recurrent venous thromboembolism. N Engl J Med 2003; 348(15): 1425- 34. 27. Ouirke W, et al. Warfarin prevalence, indications for use and haemorrhagic events. Ir Med J 2007; 100(3): 402-4. 28. Ansell J, et al. Guidelines for implementation of patient self-testing and patient self-management of oral anticoagulation. International consensus guidelines prepared by International Self-Monitoring Association for Oral Anticoagulation. Int J Cardiol 2005; 99(1): 37-45. 29.Menendez-Jandula B, et al. Comparing self-management of oral anticoagulant therapy with clinic management: a randomized trial. Ann Intern Med 2005; 142(1): 1-10. 30. Morsdorf S, et al. Training of patients for self-management of oral anticoagulant therapy: standards, patient suitability, and clinical aspects. Semin Thromb Hemost 1999; 25(1): 109-31. 31.Gadisseur AP, et al. Patient self-management of oral anticoagulant care vs. management by specialized anticoagulation clinics: positive effects on quality of life. J Thromb Haemost 2004; 2(4): 584-91. 32. Baydın A, Karataş D, Güven H, Doğanay Z, Yardan T. Retrospective evaluation of patients used warfarin admitted to emergency department. Turk J Emerg Med 2006. 6(2): 56-59. 33.Canobbio MM. Mosby’s Handbook of Patient Teaching. 3rd ed. USA:Mosby Inc. or Elsevier Inc, 2006. 34.Küçükkaya R. Oral Antikoagülan (Warfarin–Coumadin) Tedavi Hasta Kılavuzu. İstanbul: Eczacıbaşı, 2005. 35. Mercan S. Warfarin kullanan bireylerin eğitim gereksinimleri. İstanbul Üniversitesi Sağlık Bilimleri Enstitüsü, 2010. Yüksek Lisans Tezi.