Ha Nghi B, Yang Katherine, Hanigan Sarah, Kurtz Brian, Dorsch Michael P, Mak Hannah, Nagel Jerod
University of Michigan Health System, Ann Arbor, MI, USA University of Michigan, Ann Arbor, MI, USA.
University of Washington-Medicine, Seattle, WA, USA.
Ann Pharmacother. 2016 Sep;50(9):734-40. doi: 10.1177/1060028016653765. Epub 2016 Jun 16.
Drug-drug interactions (DDIs) with warfarin and antimicrobial agents are a common cause of international normalized ratio (INR) instability, which can affect the risk for bleeding and thrombotic events.
The purpose of this study was to assess the impact of a comprehensive guideline for the management of warfarin-antimicrobial DDIs across transitions of care. The guideline emphasizes improving identification of significant antimicrobial-warfarin DDIs during hospitalization, empirical warfarin dose modification based on DDI and baseline INR, patient education, documentation of the DDI, communication with outpatient providers regarding the DDI and anticipated antimicrobial stop date, and warfarin dose adjustment on discontinuation of antimicrobial.
This retrospective, single-center, quasiexperimental, pre-post study compared end points 3 months before and after guideline implementation. The primary outcome was time within therapeutic range (TTR).
The study included 78 preguideline and 31 postguideline patients; baseline characteristics were similar between groups. Implementation of the guideline resulted in greater in-hospital TTR (72% vs 50%, P = 0.04) and improved TTR across transition of care (70% vs 46%, P = 0.01). Documentation of DDI in the pharmacy anticoagulation discharge summary significantly improved in the postguideline group (40% vs 14%, P = 0.02) and numerically improved within the daily pharmacy progress notes (94% vs 82%, P = 0.13). The implementation of the guideline was associated with a nonsignificant, numerical reduction in bleeding events compared with the preguideline group (0 vs 4 events, P = 0.11).
This single-center approach to optimize the comprehensive management of significant antimicrobial-warfarin DDIs resulted in improved communication with outpatient providers and improved INR TTR.
华法林与抗菌药物之间的药物相互作用（DDIs）是国际标准化比值（INR）不稳定的常见原因，这可能会影响出血和血栓形成事件的风险。
本研究的目的是评估一项关于华法林 - 抗菌药物DDIs跨医疗转换管理的综合指南的影响。该指南强调在住院期间改善对显著抗菌药物 - 华法林DDIs的识别、基于DDI和基线INR进行经验性华法林剂量调整、患者教育、DDI的记录、与门诊提供者就DDI和预期抗菌药物停药日期进行沟通以及在抗菌药物停用后调整华法林剂量。
这项回顾性、单中心、准实验性的前后对照研究比较了指南实施前后3个月的终点。主要结局是治疗范围内的时间（TTR）。
该研究纳入了78名指南实施前患者和31名指南实施后患者；两组的基线特征相似。指南的实施使住院期间的TTR更高（72%对50%，P = 0.04），并且跨医疗转换的TTR有所改善（70%对46%，P = 0.01）。指南实施后组在药房抗凝出院小结中DDI的记录显著改善（40%对14%，P = 0.02），并且在每日药房进展记录中也有数值上的改善（94%对82%，P = 0.13）。与指南实施前组相比，指南的实施与出血事件数量的非显著减少相关（0对4起事件，P = 0.11）。
这种单中心优化显著抗菌药物 - 华法林DDIs综合管理的方法改善了与门诊提供者的沟通，并改善了INR的TTR。
