Dhippayom Teerapon, Boonpattharatthiti Kansak, Kategeaw Warittakorn, Hong Heeseung, Chaiyakunapruk Nathorn, Barnes Geoffrey D, Witt Daniel M
The Research Unit of Evidence Synthesis (TRUES), Faculty of Pharmaceutical Sciences, Naresuan University, Phitsanulok, Thailand.
Faculty of Pharmaceutical Sciences, Burapha University, Chon buri, Thailand.
EClinicalMedicine. 2024 Jul 2;74:102712. doi: 10.1016/j.eclinm.2024.102712. eCollection 2024 Aug.
The management of warfarin therapy presents clinical challenges due to its narrow therapeutic index. We aimed to evaluate the comparative effectiveness of different management strategies in patients using warfarin.
PubMed, Embase, Cochrane CENTRAL, CINAHL, and EBSCO Open Dissertation were searched from inception to 8 May 2024. Randomized controlled trials that compared the following interventions: patient self-management (PSM), patient self-testing (PST), anticoagulation management services (AMS), and usual care in patients prescribed warfarin for any indication were included. Risk ratios (RR) with 95% confidence interval (CI) were estimated using a random-effects model. Surface under the cumulative ranking curves (SUCRA) were used to rank different interventions. The certainty of evidence was assessed using the Confidence in Network Meta-Analysis (CINeMA) online platform. This study is registered with PROSPERO (CRD42023491978).
Twenty-eight trials involving 8100 participants were included, with follow-up periods of 1-24 months. Mean warfarin dosages were 4.9-7.2 mg/day. Only PSM showed a significant reduction of major TE risk compared with usual care (RR = 0.41; 95% CI: 0.24, 0.71; I = 0.0%) with moderate certainty of evidence. The 97.6% SUCRA also supported the beneficial effects of PSM over other interventions. The combined direct and indirect evidence showed significantly higher TTR in PSM compared with usual care (MD = 7.39; 95% CI: 2.39, 12.39), with very low certainty. However, direct evidence showed non-significant TTR improvement (MD = 6.49; 95% CI: -3.09, 16.07, I = 96.1%). No differences across various strategies were observed in all-cause mortality, major bleeding, stroke, transient ischemic attack, and hospitalization.
PSM reduces the risk of major TE events compared with usual care, tends to improve anticoagulation control, and should be considered where appropriate.
Agency for Healthcare Research and Quality (grant ID 5R18HS027960).
华法林治疗的管理因其狭窄的治疗指数而面临临床挑战。我们旨在评估华法林治疗患者中不同管理策略的相对有效性。
检索了从数据库建库至2024年5月8日的PubMed、Embase、Cochrane CENTRAL、CINAHL和EBSCO Open Dissertation。纳入比较以下干预措施的随机对照试验：患者自我管理（PSM）、患者自我检测（PST）、抗凝管理服务（AMS）以及对因任何适应症而开具华法林的患者的常规护理。使用随机效应模型估计95%置信区间（CI）的风险比（RR）。累积排序曲线下面积（SUCRA）用于对不同干预措施进行排序。使用网络Meta分析置信度（CINeMA）在线平台评估证据的确定性。本研究已在PROSPERO（CRD42023491978）注册。
纳入了28项试验，涉及8100名参与者，随访期为1至24个月。华法林平均剂量为4.9 - 7.2毫克/天。与常规护理相比，只有PSM显示主要血栓栓塞（TE）风险显著降低（RR = 0.41；95% CI：0.24，0.71；I² = 0.0%），证据确定性为中等。97.6%的SUCRA也支持PSM相对于其他干预措施的有益效果。合并的直接和间接证据显示，与常规护理相比，PSM中的治疗窗时间（TTR）显著更高（MD = 7.39；95% CI：2.39，12.39），确定性非常低。然而，直接证据显示TTR改善不显著（MD = 6.49；95% CI： - 3.09，16.07，I² = 96.1%）。在全因死亡率、大出血、中风、短暂性脑缺血发作和住院方面，未观察到各种策略之间的差异。
与常规护理相比，PSM可降低主要TE事件的风险，倾向于改善抗凝控制，应在适当情况下予以考虑。
医疗保健研究与质量局（资助编号5R18HS027960）。
