Drug-related problems and potential contributing factors in the management of deep vein thrombosis

Abstract

BackgroundPatients receiving anticoagulant drugs must be carefully screened for drug-related problems, as such medications, including warfarin have narrow therapeutic ranges and a high potential for complications. Thus, this study was designed to assess drug-related problems in the management of patients with deep vein thrombosis at Tikur Anbessa Specialized Hospital.MethodsA cross-sectional descriptive study involving retrospective chart review of adult patients with deep vein thrombosis was conducted from patients who visited the hospital from July 2012 to June 2013, using structured data collection format and this was complemented by key informant interview.ResultsThe study included 91 patients with venous thromboembolism. Fifty three (58.2 %) were females. Mean age was 38.6 (±13.76) years and more than 2/3 were below the age of 44 years. About 54 % of them presented with concurrent medical conditions and most commonly with cancer. Adjustment of warfarin dose up or down was done in increments of 16 to 100 % for recent subtherapeutic International Normalized Ratios, 16 to 50 % for therapeutic and 11 to 66 % for overtherapeutic International Normalized Ratios, with the mean of 36.5 (±18.03) based on the cumulative weekly dose of warfarin. There was significant linear relationship between percentage of dose change and consequent International Normalized Ratio values (R2 = 0.419; p = 0.000). Accordingly, more than 51 % of them presented with nontherapeutic International Normalized Ratio ranges following dose adjustment.ConclusionsThe most prevalent anticoagulation drug-related problems were subtherapeutic doses, overtherapeutic doses and potential drug interactions. Institutional validated decision support tools for dosing decisions during maintenance anticoagulation therapy should be developed and used accordingly in order to prevent recurrent and hemorrhagic complications and to improve clinical outcomes.

Improving anticoagulation in sub-Saharan Africa -- what are the challenges, and how can we overcome them?

“…Where detailed dose adjustment algorithms do not exist, clinicians may make erroneous or even paradoxical dose adjustments. Reviews from Cameroon, [8] Ethiopia, [9,14] and Namibia [19] report dose increases after 4%-17% of supratherapeutic INRs and dose decreases after 4%-15% of subtherapeutic INRs. In addition, dose adjustments are often inappropriately large: While clinical trial evidence has shown that warfarin dose adjustments of 10-15% were associated with better outcomes, [102] the mean warfarin dose increase in one Ethiopian review was 58% in response to an INR of 1.5 to 1.9 against a target of 2.0 to 3.0.…”

“…In addition, dose adjustments are often inappropriately large: While clinical trial evidence has shown that warfarin dose adjustments of 10-15% were associated with better outcomes, [102] the mean warfarin dose increase in one Ethiopian review was 58% in response to an INR of 1.5 to 1.9 against a target of 2.0 to 3.0. [9] In the Namibian example, more than half of patients with an INR >4 were over-corrected so that their subsequent INR was subtherapeutic. [19] Warfarin formulations other than 5mg are frequently not available in SSA, [6,22] making precision dosing difficult.…”

Deep Venous Thrombosis Recurrence and Its Predictors at Selected Tertiary Hospitals in Ethiopia: A Prospective Cohort Study

“…A similar result was found in Addis Ababa. 15 , 23 , 24 The highest incidence of DVT was varied from different studies. In most of the studies, DVT occurrence was high at a mean ± SD age of 63 ± 19.4 and 66 ± 17.…”

Improving anticoagulation in sub‐Saharan Africa: What are the challenges and how can we overcome them?

“…Where detailed dose adjustment algorithms do not exist, clinicians may make erroneous or even paradoxical dose adjustments. Reviews from Cameroon, 8 Ethiopia 9,14 and Namibia 19 report dose increases after 4‐17% of supratherapeutic INRs and dose decreases after 4‐15% of subtherapeutic INRs. In addition, dose adjustments are often inappropriately large: While clinical trial evidence has shown that warfarin dose adjustments of 10‐15% were associated with better outcomes, 103 the mean warfarin dose increase in one Ethiopian review was 58% in response to an INR of 1.5‐1.9 against a target of 2.0‐3.0 9 .…”

“…Reviews from Cameroon, 8 Ethiopia 9,14 and Namibia 19 report dose increases after 4‐17% of supratherapeutic INRs and dose decreases after 4‐15% of subtherapeutic INRs. In addition, dose adjustments are often inappropriately large: While clinical trial evidence has shown that warfarin dose adjustments of 10‐15% were associated with better outcomes, 103 the mean warfarin dose increase in one Ethiopian review was 58% in response to an INR of 1.5‐1.9 against a target of 2.0‐3.0 9 . In the Namibian example, more than half of patients with an INR >4 were over‐corrected so that their subsequent INR was subtherapeutic 19 …”