Impact of a DSS-supported medication review on the safety of drug therapy and quality of life in patients with antithrombotic therapy

Polypharmacy is common among patients with antithrombotic medication, giving rise to concerns about Drug-Related Problems (DRPs). Therefore, these patients would benefit from a Medication Review (MR) along with pharmacist counselling to reduce the risks accompanying polymedication. This prospective study presents a concept for MRs that are applicable in German community pharmacies and can efficiently support pharmacist counselling and improve the safety of drug therapy. As this is a major challenge in everyday pharmacy practice, we used a Decision Support System (DSS) to evaluate its ability to support the process of pharmacist-led MRs. The primary endpoint was the impact of a community pharmacist on the reduction of DRPs. We investigated the impact of the interventions resulting from MRs on patients taking at least one antithrombotic drug as part of their polymedication regimen. Secondary endpoints were the reduction in the number of patients with bleeding risks and the improvement of patients' Quality of Life (QoL) and therapy adherence. Furthermore, the DSS used in the study was controlled for correct data assessment and plausibility of data. We selected adult patients who were taking no less than three different medications for long-term treatment, at least one of which had to be an antithrombotic drug, and who were customers in one of eight selected pharmacies over a period of 6 months. Data from 87 patients were analyzed with DSS-support. A total of 234 DRPs were identified by the pharmacist (2.7 DRPs per patient). MR reduced DRPs by 43.2% which, resulting to a reduction of 1.2 DRPs per patient. The intervention also led to a significant improvement in the patients' QoL (assessed via EQ-5D-5L questionnaire; p < 0.001) and enhanced therapy adherence (assessed via A14 questionnaire; p < 0.001). The control of correct data assessment (with 93.8% concordance) and plausibility of data (with 91.7% concordance) of the DSS software were conducted by an external auditor. No significant effect was found for overall bleeding risk. The results of this study indicate that DSS-supported and structured MR conducted by pharmacists can contribute to a reduction in DRPs and significantly improve patient's QoL and adherence to treatment.

DOACs in the Anticoagulation of Mechanical Valves: A Systematic Review and Future Perspectives

Valvular heart disease is a common disease often necessitating valve replacement. Mechanical heart valves (MHVs) are often used in younger patients because of their longer durability. Their main disadvantage is the need for lifelong anticoagulation. Warfarin is considered a standard treatment, but it is far from perfect. Direct oral anticoagulants (DOACs) are a new and more patient-friendly alternative to warfarin when anticoagulation is required, but have not yet been approved for the indication of mechanical valves.

EVIDENCE ACQUISITION

A literature search of Pubmed, Embase, Web of Science (Core Collection), and Cochrane Library (from inception to May 2023) was performed using a search string that was well defined and not modified during the study. An extensive overview of the search terms used in each database can be found in the Appendix. Only prospective clinical trials were included in this review. A total of 10 publications were included in this review.

RELEVANCE TO CLINICAL PRACTICE

This systematic review summarizes the different types of DOACs and their possible use in the anticoagulation of mechanical valves. We aim to propose future directions in anticoagulation research for mechanical valves.

CONCLUSIONS

DOAC use in MHVs has been halted due to the failure of both dabigatran and apixaban in two major clinical trials. However, rivaroxaban was successful in two small clinical trials. Ample research is still needed to explore new valve designs as well as new anticoagulation targets.

Effect of Self-Management Program on Self-efficacy and Medication Adherence in Patients with Mechanical Heart Valve: a Randomized Clinical Trial

Introduction: Patients with mechanical heart valve need anticoagulant therapy to prevent thrombotic events. The treatment interacts with some foods and drugs. The aim was to evaluate the effect of self- management program on self-efficacy and medication adherence in patients with mechanical heart valve. Methods: This was a randomized controlled trial. eighty eligible patients, with the ability to read and speak in Farsi, aged between 15 to 60, were included in the study from the cardiac surgery clinic in Imam Khomeini hospital affiliated to Tehran University of Medical Sciences (Tehran, Iran) and randomly allocated to intervention and control groups. The participants had no history of psychiatric disorders, had undergone valve replacement surgery at least one year before the study, and were being treated with Warfarin. The intervention was a combination of 2 one- hour self-management education via small groups with 3 to 5 members, self-management educational booklets, and weekly call follow- ups for 8 weeks about 10- 15 minutes. The control group received no intervention. Self- efficacy was the primary outcome and medication adherence, Prothrombin Time (PT), and International Normalized Ratio (INR) were secondary outcomes. Data were analyzed using spss13. Results: Although the mean of self-efficacy and medication adherence, PT, and INR values were not different between the two groups at baseline, they improved significantly following the program. Conclusion: Self-management program had a positive effect on self-efficacy and medication adherence of patients with mechanical heart valve.

Effect of Home Medication Titration on Blood Pressure Control in Patients With Hypertension: A Meta-Analysis of Randomized Controlled Trials

Supplemental Digital Content is available in the text.

Background:

Medication titration has been used in home blood pressure (BP) control, with the expectation of enabling patients with hypertension to better manage their BP.

Objective:

The study goal was to estimate the effects of medication titration intervention in lowering the systolic blood pressure and diastolic blood pressure of patients with hypertension.

Methods:

The meta-analysis included randomized controlled trials on adults diagnosed with hypertension and BP≧130/80 mm Hg, having a medication-titration intervention, and using a home BP measurement. We systematically searched PubMed, CINAHL, Ovid-Medline, and the Cochrane Library, for studies published from 1997 to 2017. The quality of the studies was evaluated by the Modified Jadad scale. Statistical heterogeneity among the trials was evaluated using Q statistics and I². Publication bias was assessed with the funnel plot and Rosenthal’s fail-safe N.

Results:

The meta-analysis included 4 studies randomizing 1335 participants. Medication-titration intervention significantly assisted hypertensive patients to improve BP control; systolic blood pressure was reduced by 6.86 mm Hg [95% confidence interval (CI), 4.80-8.93, P<0.0001] and diastolic blood pressure by 3.03 mm Hg (95% CI, 2.07-3.99, P<0.0001), did not significantly affect EQ-5D scores (mean difference, 0.02; 95% CI, −0.01 to 0.04, P=0.13).

Conclusions:

Our findings suggest home medication titration of antihypertensive medication for hypertensive patients significantly improved home BP control. However, the strategy did not enhance quality of life in patients with hypertension.

A critical appraisal of point-of-care coagulation testing in critically ill patients

Derangement of the coagulation system is a common phenomenon in critically ill patients, who may present with severe bleeding and/or conditions associated with a prothrombotic state. Monitoring of this coagulopathy can be performed with conventional coagulation assays; however, point-of-care tests have become increasingly attractive, because not only do they yield a more rapid result than clinical laboratory testing, but they may also provide a more complete picture of the condition of the hemostatic system. There are many potential areas of study and applications of point-of-care hemostatic testing in critical care, including patients who present with massive blood loss, patients with a hypercoagulable state (such as in disseminated intravascular coagulation), and monitoring of antiplatelet treatment for acute arterial thrombosis, mostly acute coronary syndromes. However, the limitations of near-patient hemostatic testing has not been fully appreciated, and are discussed here. The currently available evidence indicates that point-of-care tests may be applied to guide appropriate blood product transfusion and the use of hemostatic agents to correct the hemostatic defect or to ameliorate antithrombotic treatment. Disappointingly, however, only in cardiac surgery is there adequate evidence to show that application of near-patient thromboelastography leads to an improvement in clinically relevant outcomes, such as reductions in bleeding-related morbidity and mortality, and cost-effectiveness. More research is required to validate the utility and cost-effectiveness of near-patient hemostatic testing in other areas, especially in traumatic bleeding and postpartum hemorrhage.

Atrial fibrillation and quality of life related to disease and treatment: focus on anticoagulation

ABSTRACT: 

Anticoagulation therapy is essential to reduce the risk of stroke in patients with atrial fibrillation. Traditionally, clinical trials have focused only on determining the efficacy and safety of anticoagulation but not on quality of life. In the last few years there has been a growing interest in determining the quality of life of patients treated with oral anticoagulation. In fact, specific tools that can evaluate quality of life related to atrial fibrillation and anticoagulation have been developed. Vitamin K antagonists have been shown to be effective in the prevention of thromboembolic complications. However, the use of vitamin K antagonists implies changes in behavior and lifestyle modifications that may have a negative impact on the quality of life. It has been suggested that self-monitoring of international normalized ratio could improve this impact. On the other hand, as new oral anticoagulants overcome these limitations, they may improve quality of life related with anticoagulant therapy. Unfortunately, although encouraging, the clinical experience with them is still quite limited.

Telemonitoring and self-management in the control of hypertension (TASMINH2): a cost-effectiveness analysis

AIMS

Self-monitoring and self-titration of antihypertensives (self-management) is a novel intervention which improves blood pressure control. However, little evidence exists regarding the cost-effectiveness of self-monitoring of blood pressure in general and self-management in particular. This study aimed to evaluate whether self-management of hypertension was cost-effective.

DESIGN AND METHODS

A cohort Markov model-based probabilistic cost-effectiveness analysis was undertaken extrapolating to up to 35 years from cost and outcome data collected from the telemonitoring and self-management in hypertension trial (TASMINH2). Self-management of hypertension was compared with usual care in terms of lifetime costs, quality adjusted life years and cost-effectiveness using a UK Health Service perspective. Sensitivity analyses examined the effect of different time horizons and reduced effectiveness over time from self-management.

RESULTS

In the long-term, when compared with usual care, self-management was more effective by 0.24 and 0.12 quality adjusted life years (QALYs) gained per patient for men and women, respectively. The resultant incremental cost-effectiveness ratio for self-management was £1624 per QALY for men and £4923 per QALY for women. There was at least a 99% chance of the intervention being cost-effective for both sexes at a willingness to pay threshold of £20,000 per QALY gained. These results were robust to sensitivity analyses around the assumptions made, provided that the effects of self-management lasted at least two years for men and five years for women.

CONCLUSION

Self-monitoring with self-titration of antihypertensives and telemonitoring of blood pressure measurements not only reduces blood pressure, compared with usual care, but also represents a cost-effective use of health care resources.

"MY PKU": increasing self-management in patients with phenylketonuria. A randomized controlled trial

Background

Phenylketonuria (PKU) is an autosomal recessive disorder of phenylalanine metabolism. The inability to convert phenylalanine (Phe) into tyrosine causes Phe to accumulate in the body. Adherence to a protein restricted diet, resulting in reduced Phe levels, is essential to prevent cognitive decline. Frequent evaluation of plasma Phe levels and, if necessary, adjustment of the diet are the mainstay of treatment. We aimed to assess whether increased self-management of PKU patients and/or their parents is feasible and safe, by providing direct online access to blood Phe values without immediate professional guidance.

Methods

Thirty-eight patients aged ≥ 1 year participated in a 10 month randomized controlled trial. Patients were randomized into a study group (1) or a control group (2). Group 2 continued the usual procedure: a phone call or e-mail by a dietician in case of a deviant Phe value. Group 1 was given a personal "My PKU" web page with a graph of their recent and previous Phe values, online general information about the dietary treatment and the Dutch PKU follow-up guidelines, and a message-box to contact their dietician if necessary. Phe values were provided on "My PKU" without advice. Outcome measures were: differences in mean Phe value, percentage of values above the recommended range and Phe sample frequency, between a 10-month pre-study period and the study period in each group, and between the groups in both periods. Furthermore we assessed satisfaction of patients and/or parents with the 'My PKU' procedure of online availability.

Results

There were no significant differences in mean Phe value, percentage of values above recommended range or in frequency of blood spot sampling for Phe determination between the pre-study period and the study period in each group, nor between the 2 groups during the periods. All patients and/or parents expressed a high level of satisfaction with the new way of disease management.

Conclusions

Increased self-management in PKU by providing patients and/or parents their Phe values without advice is feasible and safe and is highly appreciated.

Trial registration

The trial was registered with The Netherlands National Trial Register (NTR #1171) before recruitment of patients.

Telemonitoring and self-management in the control of hypertension (TASMINH2): a randomised controlled trial

BACKGROUND

Control of blood pressure is a key component of cardiovascular disease prevention, but is difficult to achieve and until recently has been the sole preserve of health professionals. This study assessed whether self-management by people with poorly controlled hypertension resulted in better blood pressure control compared with usual care.

METHODS

This randomised controlled trial was undertaken in 24 general practices in the UK. Patients aged 35-85 years were eligible for enrolment if they had blood pressure more than 140/90 mm Hg despite antihypertensive treatment and were willing to self-manage their hypertension. Participants were randomly assigned in a 1:1 ratio to self-management, consisting of self-monitoring of blood pressure and self-titration of antihypertensive drugs, combined with telemonitoring of home blood pressure measurements or to usual care. Randomisation was done by use of a central web-based system and was stratified by general practice with minimisation for sex, baseline systolic blood pressure, and presence or absence of diabetes or chronic kidney disease. Neither participants nor investigators were masked to group assignment. The primary endpoint was change in mean systolic blood pressure between baseline and each follow-up point (6 months and 12 months). All randomised patients who attended follow-up visits at 6 months and 12 months and had complete data for the primary outcome were included in the analysis, without imputation for missing data. This study is registered as an International Standard Randomised Controlled Trial, number ISRCTN17585681.

FINDINGS

527 participants were randomly assigned to self-management (n=263) or control (n=264), of whom 480 (91%; self-management, n=234; control, n=246) were included in the primary analysis. Mean systolic blood pressure decreased by 12.9 mm Hg (95% CI 10.4-15.5) from baseline to 6 months in the self-management group and by 9.2 mm Hg (6.7-11.8) in the control group (difference between groups 3.7 mm Hg, 0.8-6.6; p=0.013). From baseline to 12 months, systolic blood pressure decreased by 17.6 mm Hg (14.9-20.3) in the self-management group and by 12.2 mm Hg (9.5-14.9) in the control group (difference between groups 5.4 mm Hg, 2.4-8.5; p=0.0004). Frequency of most side-effects did not differ between groups, apart from leg swelling (self-management, 74 patients [32%]; control, 55 patients [22%]; p=0.022).

INTERPRETATION

Self-management of hypertension in combination with telemonitoring of blood pressure measurements represents an important new addition to control of hypertension in primary care.

FUNDING

Department of Health Policy Research Programme, National Coordinating Centre for Research Capacity Development, and Midlands Research Practices Consortium.

The International Normalized Ratio (INR) in the MELD score: problems and solutions

The Model for End-Stage Liver Disease (MELD) score is widely used to prioritize patients for liver transplantation. One of the pitfalls of the MELD score is the interlaboratory variability in all three components of the score (INR, bilirubin, creatinine). The interlaboratory variability in the INR has the largest impact on the MELD score, with a mean difference of around 5 MELD points in most studies. During the 3rd conference on Coagulopathy and Liver disease, a multidisciplinary group of scientists and physicians discussed possible solutions for the INR problem in the MELD score with the intention to provide a constructive contribution to the international debate on this issue. Here we will discuss possible solutions and highlight advantages and disadvantages.

Epidemiology and management of bleeding in patients using vitamin K antagonists

Vitamin K antagonists are effective in the prevention and treatment of a variety of arterial and venous thrombotic disorders, but are associated with an increased risk of serious bleeding complications. According to well documented studies of patients using vitamin K antagonists, the incidence of major bleeding is 0.5% per year and the incidence of intracranial bleeding is 0.2% per year, however, in real life practice this incidence may be even higher. Risk factors for bleeding are the intensity of anticoagulation, the management strategy to keep the INR in the desired range, and patient characteristics. In case of serious bleeding complications in a patient who uses vitamin K antagonists, this anticoagulant treatment can be quickly reversed by administration of vitamin K or coagulation factor concentrates.