The more risks are related to a drug, the more details must be discussed with the patient. On the other hand patients simply often are not rational. Fear tends to undermine reason and that's why the patient does not always decide and act in such a way, as it is good for him or her. The physician needs to foresee special risks if a patient seems to have losses in sensory perception. With other words the physician is advised to point out possible side effects of the anticoagulant.
For a sustained compliance it is first the physician’s responsibility to inform and instruct the anticoagulated patients in a corresponding manner. But often the time for the instructions is limited (five minutes medicine) and that leads to it that patients are left with a prescription and only a single advice, but without any kind of formalised support (Hugo ten Cate, Thrombosis and Haemostasis 107.5/2012).
Coagulation self-management/testing involves great self-confidence. The experience of self-dealing with anticoagulation supports in my opinion a sustained compliance and of course a higher quality of life. The anticoagulated patient is motivated to continue the therapy. Motivation begins with the weekly INR determination and the question: Am I in the therapeutic range? If not, what was wrong and what can I change in my life to possibly improve?
Time and attention from physician's side improves compliance, drug adherence and stable INR-values!
Comments:
Great Christian. The problem you focus on is indeed very relevant. Patients getting anticoagulated are frequently not well informed. In particular, those receiving the new oral anticoagulants (DOAK) often only get the prescription and no information at all. Due to missing information they often believe that DOAK are medications with only positive effects, but without any side effects (and some physicians appear to believe this, too). To my personal experience, based on more than 2.000 anticoagulated patients each year, patients receiving vitamin K antagonists (VKA) are much better informed on the effects and side effects of their anticoagulation. They have to visit their physicians more often to control INR and adjust the VKA dosage and get more and more information. Patients performing a self-management (PSM) are of course best informed and trained, since they receive a standard training program including all relevant aspects of their anticoagulation. The strategy to only prescribe the medication and not to see him again in the case of DOAK was sometime described us "fire and forget strategy". In my opinion this is a very critical point in many patients receiving DOAK. In general, it is very important to realize that not every patient is suitable for every option of anticoagulation. It is very good to have new options with the introduction of the DOAK. However, taking DOAK should be reduced to absolutely compliant and adherent patients, since the short half-life compared to the long-acting VKA may lead to loss of the antithrombotic effects if only one dose is not taken. Some physicians switch their non-adherent and non-compliant patients from VKA to DOAK. It always astonishes me how someone can believe that patients not taking the VKA pill consequently will take the DOAK pill! The only point is that physicians are widely no more confronted with noncompliance in patients taking DOAK, because they see the patient much less frequently and non-compliance is not so apparent since the anticoagulant effect of DOAK is not regularly checked with a laboratory assay. I strongly believe that testing anticoagulant effects in patients with any anticoagulant allows a better control of anticoagulation improves adherence and helps to optimize the efficacy and reduce the side effects due to over- and under anticoagulation. Today, this is best established for PSM patients!
Christoph Sucker, MD, Berlin, gerinnungszentrum-berlin.de
