Evaluation of pharmacist-based compared to doctor-based anticoagulation management in Qatar

RATIONALE, AIMS AND OBJECTIVES

For over 60 years, warfarin has been the mainstay anticoagulant used in the outpatient setting for the prevention and treatment of a wide variety of thromboembolic clinical conditions. Guidelines recommend that health care providers managing oral anticoagulation therapy should do so in a systematic and coordinated fashion. Studies have shown that, when compared to traditional doctor-based anticoagulation management, pharmacist-managed anticoagulation services can improve patient outcomes. The first pharmacist-based anticoagulation clinic in Qatar was launched in 2013 at Alwakra Hospital. The primary objective of this research was to evaluate the impact of pharmacist versus doctor-based anticoagulation management on the percentage time under therapeutic INR (International Normalized Ratio; TTR), INR within therapeutic range and the extreme out of range INRs.

METHOD

A retrospective cohort study was designed to compare the anticoagulation control of pharmacist-based warfarin clinic to the usual doctor-care.

RESULTS

Data from 278 patients taking warfarin (78 managed at pharmacist and 200 at doctor-based clinic) were evaluated. Subjects followed at the pharmacist-based clinic had a superior TTR compared to those managed at the doctor-based clinic (81.8% vs. 69.8%, P < 0.001). Additionally, the percentage of visits within therapeutic range were significantly higher in the pharmacist's group compared to doctor's group (76.5% vs. 71.2%, P = 0.011). At the same time, percentage of visits with extreme subtherapeutic INR was reduced in the pharmacist-managed clinic (5.17% vs. 7.05%, P = 0.007) CONCLUSIONS: Our study indicates that pharmacist-based anticoagulation has better INR control when compared to the traditional anticoagulation management. Pharmacist-managed anticoagulation clinics should be considered and supported for warfarin management.

Serum gastrin in chronic renal failure: morphological and physiological correlations

Elevated serum gastrin (SG) has been reported in chronic renal failure (CRF). We studied SG levels in relation to various humoral and gastroduodenal histopathologic findings in 20 controls, 12 uremics under conservative therapy (CT), 27 patients on regular dialysis (RDT) and 8 transplanted patients (Tx). SG and parathyroid hormone (PTH) levels were estimated by radioimmunoassay (RIA), in addition serum BUN, creatinine, Ca++PO4---and alkaline phosphatase (predialysis in RDT) were determined. 20 patients (12 on CT and 8 on RDT) underwent pentagastrin (PG) stimulation test and upper gastrointestinal endoscopy with biopsy of gastric and duodenal mucosa. The mucosal samples were stained for mucopolysaccharides (MPS), nucleic acid (NA) and alkaline phosphatase (AP), and divided into intense, normal or faint staining. Mean SG was 688.71 pg/ml (CT cases), 636.2 pg/ml (RDT cases) and 280.6 pg/ml (Tx cases), all values being significantly higher than controls (118.46 pg/ml). SG level had a linear correlation with serum creatinine in CT patients and predialysis creatinine in RDT patients, but not with other parameters studied (BUN, Ca++,PTH,PO4---AP). The incidence of gastroduodenal erosions (40%) had a significant negative correlation with SG. They were more frequent with normal MPS stain (p = 0.01) and NA staining (p less than 0.001) than faint staining of gastric mucosa biopsy. The acid response to PG stimulation was inversely correlated with SG. We believe that elevated SG is compensatory to a decreased response of the gastroduodenal mucosa to PG. Mere retention of SG does not explain its elevation as its correlation with serum creatinine existed not only in patients on CT, but also in RDT patients.(ABSTRACT TRUNCATED AT 250 WORDS)