Bleeding Incidence in Patients Administered with Warfarin at Secondary Hospitals in Yogyakarta Province
Keywords:
Warfarin, Dosage, Bleeding Incidence, Secondary Hospital
Abstract
Warfarin is an oral anticoagulant most-commonly prescribed for prevention and treatment of thromboembolism. It is widely acknowledged that warfarin has both narrow therapeutic index and various drug-food interactions, thus carrying the risk of subtherapeutic or bleeding. Therefore, warfarin is among the priority drugs to be evaluated to improve the quality of care for warfarin use. This study aimed to analyze the indications and dosage as well as the bleeding incidence in warfarin use at secondary hospitals in Yogyakarta. This research employed the retrospective cross-sectional design among outpatients and inpatients who received warfarin for a minimum of three days. Data of patient demographics, indications and doses of warfarin, incidence of bleeding, and other drugs interacting with warfarin were collected from the medical records for two years of research. The bleeding incidence could include conjunctival bleeding, melena, hematemesis, petechiae, purpura, ecchymosis, or hematochezia as was documented in the medical records. The research involved 139 patients with a majority of male patients and age range of >60 years. The three highest indications of warfarin use were CHF (37.41%), CHF-AF (23.74%), and AF (10.79%) with an average dose of 1.83±0.54 mg/day. Despite the administration of low doses of warfarin, four patients (2.90%) experienced bleeding with hematuria as the main clinical manifestation. This study recommends adjusting to a lower warfarin dose, particularly for the elderly who receive a combination with aspirin. In addition to a lower maintenance dose, a lower therapeutic target of INR should be further verified for Indonesian patients who receive warfarin.
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Furdiyanti, N. H., Pramantara, I. D. P., & Wahyono, D. (2014). Evaluation of Warfarin Dosing and Its Clinical Outcome in Outpatients (Journal of Management and Pharmacy Practice), 4(3), 175–179. https://doi.org/10.22146/jmpf.284
Ge, B., Zhang, Z., & Zuo, Z. (2014). Updates on the Clinical Evidenced Herb-Warfarin Interactions. Evidence-Based Complementary and Alternative Medicine : ECAM, 2014. https://doi.org/10.1155/2014/957362
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Hylek, E. M., Evans-Molina, C., Shea, C., Henault L. E., & Regan S. (2007). Major Hemorrhage and Tolerability of Warfarin in the First Year of Therapy Among Elderly Patients With Atrial Fibrillation. Circulation, 115(21), 2689–2696. https://doi.org/10.1161/CIRCULATIONAHA.106.653048
Kamthornthanakarn, I., & Krittayaphong, R. (2019). Optimal INR level for warfarin therapy after mechanical mitral valve replacement. BMC Cardiovascular Disorders, 19. https://doi.org/10.1186/s12872-019-1078-3
Kasner, S. E., Wang, L., French, B., Messé, S. R., Ellenberg, J., & Kimmel, S. E. (2016). Warfarin Dosing Algorithms and the Need for Human Intervention. The American Journal of Medicine, 129(4), 431–437. https://doi.org/10.1016/j.amjmed.2015.11.012
Katritsis, D. G., Gersh, B. J., & Camm, A. J. (2015). Anticoagulation in Atrial Fibrillation – Current Concepts. Arrhythmia & Electrophysiology Review, 4(2), 100–107. https://doi.org/10.15420/aer.2015.04.02.100
Kemenkes RI. (2019a). Petunjuk Teknis Standar Pelayanan Kefarmasian di Rumah Sakit. http://farmalkes.kemkes.go.id/2020/01/petunjuk-teknis-standar-pelayanan-kefarmasian-di-rumah-sakit/
Kemenkes RI, B. P. dan P. K. (2019b). Hasil Utama Riskesdas 2018.
Khalili, H., Dashti-Khavidaki, S., Talasaz, A. H.-H., Najmedin, F., & Hosseinpoor, R. (2010). Anticoagulant utilization evaluation in a teaching hospital: A prospective study. Journal of Pharmacy Practice, 23(6), 579–584. https://doi.org/10.1177/0897190010372808
Kim, Y., Park, E. S., Kang, D.-W., Kim, T. J., & Lee, S.-H. (2019). Maintenance dose of warfarin beyond time in therapeutic range for preventing vascular events. Journal of the Neurological Sciences, 398, 69–74. https://doi.org/10.1016/j.jns.2019.01.031
Krumholz, H. M., Bona, R., Jaser, L., Classen, D., Wang, Y., Eldridge, N., Metersky, M. L., Metersky, M. L., Eckenrode, S., Bakullari, A., & Andrawis, M. (2016). Predictors of warfarin‐associated adverse events in hospitalized patients: Opportunities to prevent patient harm. Journal of Hospital Medicine, 11(4). https://doi.org/10.1002/jhm.2528
Kuruvilla, M., & Gurk-Turner, C. (2001). A review of warfarin dosing and monitoring. Proceedings (Baylor University. Medical Center), 14(3), 305–306. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1305837/
Laäs, D. J., & Naidoo, M. (2018). An evaluation of warfarin use at an urban district-level hospital in KwaZulu-Natal Province, South Africa. South African Medical Journal, 108(12), 1046-1050–1050. https://doi.org/10.7196/SAMJ.2018.v108i12.13256
Mak, M., Lam, C., Pineda, S. J., Lou, M., Xu, L. Y., Meeks, C., Lin, C., Stone, R., Rodgers, K., & Mitani, G. (2019). Pharmacogenetics of Warfarin in a Diverse Patient Population. Journal of Cardiovascular Pharmacology and Therapeutics, 24(6), 521–533. https://doi.org/10.1177/1074248419843530
Mangoni, A. A., & Jackson, S. H. D. (2004). Age-related changes in pharmacokinetics and pharmacodynamics: Basic principles and practical applications. British Journal of Clinical Pharmacology, 57(1), 6–14. https://doi.org/10.1046/j.1365-2125.2003.02007.x
Miura, T., Nishinaka, T., Terada, T., & Yonezawa, K. (2009). Relationship between aging and dosage of warfarin: The current status of warfarin anticoagulant therapy for Japanese outpatients in a department of cardiovascular medicine. Journal of Cardiology, 53(3), 355–360. https://doi.org/10.1016/j.jjcc.2008.12.003
Mosca, L., Barrett-Connor, E., & Kass Wenger, N. (2011). Sex/Gender Differences in Cardiovascular Disease Prevention: What a Difference a Decade Makes. Circulation, 124(19), 2145–2154. https://doi.org/10.1161/CIRCULATIONAHA.110.968792
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Published
2020-09-30
How to Cite
D.A Ningrum, V., Sufiyah, S., Dyah Widyastuti, I., Sufriyanto Yusuf, B., & Dullah, W. (2020). Bleeding Incidence in Patients Administered with Warfarin at Secondary Hospitals in Yogyakarta Province. Indonesian Journal of Pharmacy, 31(3), 217-228. https://doi.org/10.22146/ijp.814
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