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Warfarin in the Emergency Service: Drug Interactions and Clinical Considerations

Year 2024, Volume: 15 Issue: 2, 234 - 239, 01.07.2024
https://doi.org/10.18663/tjcl.1470923

Abstract

Aim: Drug-drug interactions (DDIs) are common occurrences where one drug influences the blood concentrations or efficacy of another. Warfarin, known for its narrow therapeutic index, carries a heightened risk of severe drug interactions.
Material and Methods: We retrospectively analyzed the records of 211 patients using warfarin at the Emergency Health Services clinic of Kırklareli Training and Research Hospital from January 1, 2020, to December 31, 2020. Patient demographics and drug regimens were documented, and drug interaction assessments were conducted using the drugs.com database.
Results: Among the 211 patients, 17 exhibited signs of bleeding, including 5 with major bleeding and 12 with minor bleeding. Of these, 129 had INR values exceeding 2.5, while 82 had INR values below 2.5. Notably, 11 of the 17 bleeding patients had INR values above 2.5, with an average INR of 3.69. Analysis revealed that the 211 patients collectively used 111 different drugs, with an average of 3.81 drugs per prescription. Intriguingly, 33 of these drugs exhibited major, moderate, or minor inter-actions and were prescribed to 174 patients.
Conclusion: In conclusion, cautious and selective prescription of medications is warranted for patients receiving warfarin due to the potential for significant drug interactions.

References

  • Becker M, Kallewaard M, Caspers PWJ, Visser LE, Leuens HGM and Stricker BH Ch, Hospitalisations and emergency department visits due to drug-drug interactions: a literature review, Pharmacoepidemiol. Drug Saf. 2007; 16(6) :641–51.
  • Bénard‐Laribière A, Miremont‐Salamé G, Pérault‐Pochat M‐C, Noize P, Haramburu F. The EMIR study group on behalf of the French network of pharmacovigilance centres. Incidence of hospital admissions due to adverse drug reactions in France: the EMIR study. Fundam Clin Pharmacol. 2015;29(1):106‐11.
  • Budnitz DS, Shehab N, Kegler SR, Richards CL. Medication use leading to emergency department visits for adverse drug events in older adults. Ann Intern Med. 2007;147(11):755–65.
  • Campbell CJ, Sefton M. Discharge teaching about warfarin: patient retention of knowledge. Have home care patients been taught what they need to know. Home Healthcare Nurse. 2010;28(6):366-74.
  • Carpenter M, Berry H, Pelletier AL. Clinically Relevant Drug-Drug Interactions in Primary Care. Am Fam Physician. 2019;99(9):558-64.
  • Dechanont S, Maphanta S, Butthum B, Kongkaew C. Hospital admissions/visits associated with drug–drug interactions: a systematic review and meta‐analysis. Pharmacoepidemiol Drug Saf. 2014;23(5):489‐97.
  • Eschenbacher L. PT, INR, and APTT testing. Washington State Department Of Health Elaborations News And İssues For Washington’s Clinical Laboratories. 2018;23(2):1-5.
  • Fihn SD, Callahan CM, Martin DC, McDonell MB, Henikoff JG, White RH. The risk for and severity of bleeding complications in elderly patients treated with warfarin. The National Consortium of Anticoagulation Clinics. Ann Intern Med. 1996;124(11):970-9.
  • Gallus AS, Baker RI, Chong BH, Ockelford PA, Street AM. Consensus guidelines for warfarin therapy. Recommendations from the Australasian Society of Thrombosis and Haemostasis. Med J Aust. 2000;172(12):600-5.
  • Guidelines for warfarin management in the community, January. 2016
  • Hall AM, Wilkins MR. Warfarin: a case history in pharmacogenetics, Heart 2005;91(5):563-564.
  • Henry M, Kay MM, Viccellio P. Cardiogenic shock associated with calcium-channel and beta blockers: reversal with intravenous calcium chloride. Am J Emerg Med. 1985;3(4):334-6.
  • Kaplan NM. Amlodipine in the treatment of hypertension. Postgrad Med J. 1991;67 Suppl 5:s15-9.
  • Karabağ E. Concurrent Use of NSAIDs in Patients Taking Metoprolol and Drug Interaction. [Master’s dissertation]. Istanbul Medipol University. Istanbul. 2019.
  • Moran SM, Fitzgerald N, Pope M, Madden M, Vaughan CJ. Warfarin anticoagulation: a survey of patients’ knowledge of their treatment. Ireland Journal Medicine Science. 2011; (180):819-22.
  • Nikolic B, Jankovic S, Stojanov O, Popovic J. Prevalence and predictors of potential drug-drug interactions. Cent Eur J Med. 2014;9(2):348-56.
  • Palareti G, Leali N, Coccheri S, Poggi M, Manotti C, D'Angelo A, Pengo V, Erba N, Moia M, Ciavarella N, Devoto G, Berrettini M, Musolesi S. 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.
  • Pirmohamed M, James S, Meakin S, Green C, Scott AK, Walley TJ, et al. Adverse drug reactions as cause of admission to hospital: Prospective analysis of 18 820 patients. BMJ. 2004;329(7456):15–9.
  • Polat O, Kabaçam G, Güler İ, Ergişi K, Yıldız A. Surveillance analysis of patients presenting to the Ibn-i Sina Hospital Emergency Department. Turk J Emerg Med. 2005;5(2):78-81.
  • Routledge PA, O'Mahony MS, Woodhouse KW. Adverse drug reactions in elderly patients. Br J Clin Pharmacol. 2004;57(2):121–6.
  • Shehab N, Lovegrove MC, Geller AI, Rose KO, Weidle NJ, Budnitz DS. US Emergency Department visits for outpatient adverse drug events, 2013-2014. JAMA. 2016;316(20):2115–25.
  • Wallvik J. Sjalander A. Johansson L. Bjuhr O. Jansson JH. Bleeding complications during warfarin treatment in primary healthcare centres compared with anticoagulation clinics. Scand J Prim Health Care. 2007; 25(2): 123-28.

Acil Serviste Warfarin: İlaç Etkileşimleri ve Klinik Önlemler

Year 2024, Volume: 15 Issue: 2, 234 - 239, 01.07.2024
https://doi.org/10.18663/tjcl.1470923

Abstract

Amaç: İlaç-ilaç etkileşimleri (İİE'ler), bir ilacın diğerinin kan konsantrasyonlarını veya etkinliğini etkilediği yaygın durumlardır. Dar terapötik indeksi ile bilinen warfarin, ciddi ilaç etkileşimleri açısından yüksek risk taşır.
Gereç ve Yöntem: 1 Ocak 2020 ile 31 Aralık 2020 tarihleri arasında Kırklareli Eğitim ve Araştırma Hastanesi Acil Sağlık Hizmetleri kliniğinde warfarin kullanan 211 hastanın kayıtları retrospektif olarak analiz edildi. Hasta demografileri ve ilaç rejimleri belgelendi ve ilaç etkileşim değerlendirmeleri drugs.com veritabanı kullanılarak yapıldı.
Bulgular: 211 hastadan 17'sinde kanama belirtileri görüldü; bunlardan 5'i büyük, 12'si küçük kanamalardı. 129 hastanın INR değerleri 2,5'in üzerindeyken, 82 hastanın INR değerleri 2,5'in altındaydı. Kanama yaşayan 17 hastadan 11'inin INR değeri 2,5'in üzerindeydi ve ortalama INR değeri 3,69'du. Analiz sonucunda, 211 hastanın toplamda 111 farklı ilaç kullandığı ve reçete başına ortalama 3,81 ilaç bulunduğu tespit edildi. İlginç bir şekilde, bu ilaçların 33'ü majör, orta veya minör etkileşimler gösterdiği ve 174 hastaya reçete edildiği görüldü.
Sonuç: Sonuç olarak, warfarin kullanan hastalar için ilaç etkileşimleri potansiyeli nedeniyle ilaç reçetelendirmesi dikkatli ve seçici bir şekilde yapılmalıdır.

Ethical Statement

The study was conducted in accordance with the Declaration of Helsinki, and approved by the Institutional Review Board (or Ethics Committee) of Kırklareli University Faculty of Medicine (protocol codeand date of approval 03/04/2024 - P202400011).

Thanks

Sayın Editör, Makalemi değerlendirmeniz için göndermekten memnuniyet duyuyorum. Bu süreçte gösterdiğiniz ilgi ve alaka için teşekkür ederim. Umarım makalem derginiz için uygun bulunur ve bilimsel camiaya katkıda bulunur. Her türlü soru ve geri bildirime açığım ve sürecin her aşamasında işbirliği içinde olmayı dört gözle bekliyorum. Saygılarımla, Dr. Tuğçe Uskur

References

  • Becker M, Kallewaard M, Caspers PWJ, Visser LE, Leuens HGM and Stricker BH Ch, Hospitalisations and emergency department visits due to drug-drug interactions: a literature review, Pharmacoepidemiol. Drug Saf. 2007; 16(6) :641–51.
  • Bénard‐Laribière A, Miremont‐Salamé G, Pérault‐Pochat M‐C, Noize P, Haramburu F. The EMIR study group on behalf of the French network of pharmacovigilance centres. Incidence of hospital admissions due to adverse drug reactions in France: the EMIR study. Fundam Clin Pharmacol. 2015;29(1):106‐11.
  • Budnitz DS, Shehab N, Kegler SR, Richards CL. Medication use leading to emergency department visits for adverse drug events in older adults. Ann Intern Med. 2007;147(11):755–65.
  • Campbell CJ, Sefton M. Discharge teaching about warfarin: patient retention of knowledge. Have home care patients been taught what they need to know. Home Healthcare Nurse. 2010;28(6):366-74.
  • Carpenter M, Berry H, Pelletier AL. Clinically Relevant Drug-Drug Interactions in Primary Care. Am Fam Physician. 2019;99(9):558-64.
  • Dechanont S, Maphanta S, Butthum B, Kongkaew C. Hospital admissions/visits associated with drug–drug interactions: a systematic review and meta‐analysis. Pharmacoepidemiol Drug Saf. 2014;23(5):489‐97.
  • Eschenbacher L. PT, INR, and APTT testing. Washington State Department Of Health Elaborations News And İssues For Washington’s Clinical Laboratories. 2018;23(2):1-5.
  • Fihn SD, Callahan CM, Martin DC, McDonell MB, Henikoff JG, White RH. The risk for and severity of bleeding complications in elderly patients treated with warfarin. The National Consortium of Anticoagulation Clinics. Ann Intern Med. 1996;124(11):970-9.
  • Gallus AS, Baker RI, Chong BH, Ockelford PA, Street AM. Consensus guidelines for warfarin therapy. Recommendations from the Australasian Society of Thrombosis and Haemostasis. Med J Aust. 2000;172(12):600-5.
  • Guidelines for warfarin management in the community, January. 2016
  • Hall AM, Wilkins MR. Warfarin: a case history in pharmacogenetics, Heart 2005;91(5):563-564.
  • Henry M, Kay MM, Viccellio P. Cardiogenic shock associated with calcium-channel and beta blockers: reversal with intravenous calcium chloride. Am J Emerg Med. 1985;3(4):334-6.
  • Kaplan NM. Amlodipine in the treatment of hypertension. Postgrad Med J. 1991;67 Suppl 5:s15-9.
  • Karabağ E. Concurrent Use of NSAIDs in Patients Taking Metoprolol and Drug Interaction. [Master’s dissertation]. Istanbul Medipol University. Istanbul. 2019.
  • Moran SM, Fitzgerald N, Pope M, Madden M, Vaughan CJ. Warfarin anticoagulation: a survey of patients’ knowledge of their treatment. Ireland Journal Medicine Science. 2011; (180):819-22.
  • Nikolic B, Jankovic S, Stojanov O, Popovic J. Prevalence and predictors of potential drug-drug interactions. Cent Eur J Med. 2014;9(2):348-56.
  • Palareti G, Leali N, Coccheri S, Poggi M, Manotti C, D'Angelo A, Pengo V, Erba N, Moia M, Ciavarella N, Devoto G, Berrettini M, Musolesi S. 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.
  • Pirmohamed M, James S, Meakin S, Green C, Scott AK, Walley TJ, et al. Adverse drug reactions as cause of admission to hospital: Prospective analysis of 18 820 patients. BMJ. 2004;329(7456):15–9.
  • Polat O, Kabaçam G, Güler İ, Ergişi K, Yıldız A. Surveillance analysis of patients presenting to the Ibn-i Sina Hospital Emergency Department. Turk J Emerg Med. 2005;5(2):78-81.
  • Routledge PA, O'Mahony MS, Woodhouse KW. Adverse drug reactions in elderly patients. Br J Clin Pharmacol. 2004;57(2):121–6.
  • Shehab N, Lovegrove MC, Geller AI, Rose KO, Weidle NJ, Budnitz DS. US Emergency Department visits for outpatient adverse drug events, 2013-2014. JAMA. 2016;316(20):2115–25.
  • Wallvik J. Sjalander A. Johansson L. Bjuhr O. Jansson JH. Bleeding complications during warfarin treatment in primary healthcare centres compared with anticoagulation clinics. Scand J Prim Health Care. 2007; 25(2): 123-28.
There are 22 citations in total.

Details

Primary Language English
Subjects Medical Pharmacology, Emergency Medicine
Journal Section Research Article
Authors

Tugce Uskur 0000-0001-6626-4859

Oya Güven 0000-0002-6389-4561

Merve Demireller 0000-0002-5580-6015

Publication Date July 1, 2024
Submission Date April 19, 2024
Acceptance Date May 21, 2024
Published in Issue Year 2024 Volume: 15 Issue: 2

Cite

APA Uskur, T., Güven, O., & Demireller, M. (2024). Warfarin in the Emergency Service: Drug Interactions and Clinical Considerations. Turkish Journal of Clinics and Laboratory, 15(2), 234-239. https://doi.org/10.18663/tjcl.1470923
AMA Uskur T, Güven O, Demireller M. Warfarin in the Emergency Service: Drug Interactions and Clinical Considerations. TJCL. July 2024;15(2):234-239. doi:10.18663/tjcl.1470923
Chicago Uskur, Tugce, Oya Güven, and Merve Demireller. “Warfarin in the Emergency Service: Drug Interactions and Clinical Considerations”. Turkish Journal of Clinics and Laboratory 15, no. 2 (July 2024): 234-39. https://doi.org/10.18663/tjcl.1470923.
EndNote Uskur T, Güven O, Demireller M (July 1, 2024) Warfarin in the Emergency Service: Drug Interactions and Clinical Considerations. Turkish Journal of Clinics and Laboratory 15 2 234–239.
IEEE T. Uskur, O. Güven, and M. Demireller, “Warfarin in the Emergency Service: Drug Interactions and Clinical Considerations”, TJCL, vol. 15, no. 2, pp. 234–239, 2024, doi: 10.18663/tjcl.1470923.
ISNAD Uskur, Tugce et al. “Warfarin in the Emergency Service: Drug Interactions and Clinical Considerations”. Turkish Journal of Clinics and Laboratory 15/2 (July 2024), 234-239. https://doi.org/10.18663/tjcl.1470923.
JAMA Uskur T, Güven O, Demireller M. Warfarin in the Emergency Service: Drug Interactions and Clinical Considerations. TJCL. 2024;15:234–239.
MLA Uskur, Tugce et al. “Warfarin in the Emergency Service: Drug Interactions and Clinical Considerations”. Turkish Journal of Clinics and Laboratory, vol. 15, no. 2, 2024, pp. 234-9, doi:10.18663/tjcl.1470923.
Vancouver Uskur T, Güven O, Demireller M. Warfarin in the Emergency Service: Drug Interactions and Clinical Considerations. TJCL. 2024;15(2):234-9.


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