The Fast Paced World of Anti-Coagulation

This past week I have had the opportunity to work in the anti-coagulation clinic at the VA. It is a fast paced clinic with only 15 minutes allotted for each appointment. While that may not sound like a big deal to some, consider all that must be accomplished during those 15 minutes.
The pharmacist must first use a point of care (POC) INR meter to asses whether the patients INR is in the therapeutic range... while the meter is reading the blood sample you pray that it is...

If you are fortunate enough to have a patient who is well organized and hasn't had any medical or dietary changes and has a therapeutic INR then your job becomes fairly easy for the rest of the appointment during which you simply need to renew/refill the patient's warfarin prescription, schedule a date four weeks down the road to see them again, and chart your encounter on the patient's electronic medical record.

It often becomes interesting when a patient's INR is not within the therapeutic range. First, you must interrogate the patient in an effort to determine why the INR is out of range (i.e. how much coleslaw, potato salad, and broccoli did you have over the holiday weekend).
Next, you must determine what adjustments, if any, should be made. While algorithms do exist to determine dosage adjustments for various INRs, you quickly learn that they are not very specific (i.e. If INR <1.6 then adjust weekly dose by 5-20%) and that there is an art form to making adjustments that will bring the INR back to where it should be.
Once you decide how to manage the INR you need to clearly communicate the changes to the patient then complete the appointment as described above.

In addition to the above scenarios a couple of times each week you will encounter patients needing bridge therapy for upcoming procedures. Bridging typically consists of starting low molecular weight heparin (LMWH) and stopping warfarin before certain procedures to minimize bleeding risk as well as keeping the patient anti-coagulated. ( I know from experience that a bridge patient will certainly not allow you to stay on time).

While it sounds hectic (and it often is) the anti-coagulation clinics decrease health care costs associated with warfarin related bleeding as well as improve patient outcomes in various disease states requiring anti-coagulation.

Stay tuned for next time where I will discuss the results of my cost analysis of pharmacist managed warfarin clinics vs. dabigatran therapy...