Berg Tamara M, O'Meara John G, Ou Narith N, Daniels Paul R, Moriarty James P, Bergstrahl Eric J, Dierkhising Ross A, Manning Dennis M
Department of Pharmacy Services, Mayo Clinic, Rochester, Minnesota.
Pharmacotherapy. 2013 Nov;33(11):1165-74. doi: 10.1002/phar.1280. Epub 2013 Apr 26.
To identify specific risk factors for excessive anticoagulation, defined as an international normalized ratio (INR) higher than 5, in hospitalized adults receiving warfarin therapy using a pharmacist-managed dosing protocol.
Retrospective nested case-control study.
Large academic tertiary care medical center.
Hospitalized nonsurgical patients 18 years or older who received at least one dose of warfarin according to the pharmacist-managed protocol from January 1, 2009, to January 31, 2012, were included. Patients who experienced an INR higher than 5 were designated as case patients; those who received warfarin for at least as many days as the case patients but who did not experience an INR more than 5 were deemed control patients. Controls were matched to cases in a 2:1 ratio by age, sex, INR goal, and type of warfarin therapy (new start or continuation).
A total of 87 case patients were matched to 174 controls. Ten different hypothesized risk factors were examined. Two variables, severity of illness score (odds ratio [OR] 4.89, p<0.001) and poor nutritional status (OR 4.27, p<0.001), demonstrated strong independent associations with risk of excessive anticoagulation. Administration of interacting drugs that highly potentiate warfarin's effect (OR 2.26, p=0.011) and concurrent diarrheal illness (OR 4.75, p<0.001) also displayed a statistically significant risk for excessive anticoagulation.
Even in a highly standardized system for warfarin dosing by a pharmacist-managed protocol, higher disease severity and poor nutritional status placed hospitalized patients at greater risk of experiencing excessive anticoagulation. In addition, administration of interacting drugs that highly potentiate warfarin's effect or the occurrence of diarrheal illness may predict increased risk.
采用药剂师管理的给药方案，确定接受华法林治疗的住院成年患者过度抗凝（定义为国际标准化比值[INR]高于5）的具体危险因素。
回顾性巢式病例对照研究。
大型学术性三级医疗中心。
纳入2009年1月1日至2012年1月31日期间根据药剂师管理方案接受至少一剂华法林治疗的18岁及以上住院非手术患者。INR高于5的患者被指定为病例组患者；接受华法林治疗天数至少与病例组患者相同但INR未超过5的患者被视为对照组患者。对照组按年龄、性别、INR目标和华法林治疗类型（新开始或继续治疗）以2:1的比例与病例组匹配。
共87例病例组患者与174例对照组患者匹配。研究了10种不同的假设危险因素。两个变量，疾病严重程度评分（比值比[OR]4.89，p<0.001）和营养状况差（OR 4.27，p<0.001），与过度抗凝风险呈强烈独立关联。使用高度增强华法林作用的相互作用药物（OR 2.26，p=0.011）和并发腹泻病（OR 4.75，p<0.001）也显示出过度抗凝的统计学显著风险。
即使在药剂师管理方案对华法林给药进行高度标准化的系统中，疾病严重程度较高和营养状况较差也使住院患者面临更高的过度抗凝风险。此外，使用高度增强华法林作用的相互作用药物或腹泻病的发生可能预示风险增加。
