Modern life with anticoagulants

Oral anticoagulant therapy (OAT) with warfarin has been used for more than 60 years to prevent blood from clotting inside the heart or in blood vessels. In spite of a wide spectrum of newer drugs available on the market, scientific studies with warfarin has repeatedly proven this drug as most effective for several applications and it has also been verified as a drug with remarkably few side effects.

The therapeutic interval is very small

The downside of this therapy has always been the narrow margin between success and failure.  The therapeutic interval where the patient has diminished risk of thrombus formation on one hand and low risk of bleeding on the other hand is very small. Managing this therapy within the safety margins has often been compared with the mythological sea fare between Scylla and Charybdis where bad navigation, unpredictable currents or winds may have fatal consequences for the sailors.

Self empowerment of the patients

Traditionally OAT has been monitored by INR analyses performed at a hospital or at the family doctor. The modern modality of patient self management is a concept well filled to modern patients where self empowerment is considered an advantage because the patient is deeply involved and very knowledgeable about the therapy and its management. Using the analogy of Scylla and Charybdis you are a safer navigator with your own boat, which you know inside and out, than a doctor who is trained to navigate hundreds of boats. Doctors will never be “on board” and will never know as many details as the patient knows about him/herself. Self management therefore, enables the patient to become a health care collaborator on his/her own therapy – not just in a traditional patient role. The option of home monitoring of INR alleviates the patient from being kept in a patient’s role which entails visiting hospital or family doctor for OAT monitoring. He/she can live a normal life with travel, work and study without the need of coordinating schedules. Another – and maybe more important – aspect of patient self management is the frequency of INR measurements which allows for a more intensive monitoring of the therapy than what is practically feasible in the conventional health care system. This means that changes in warfarin need is being detected early and can be dealt with before INR reach dangerously high or low values. In many ways modern management of OAT has significant similarities with diabetes management. This therapy has become much easier and with better quality since home glucometers have become available and since training of patients has become and integrated element of the therapy.

Patients need to take responsibility

Diabetic patients have become empowered to control insulin intake according to their needs in stead of letting a set insulin dosage dictate their daily life. In the same way self managing OAT patients have become empowered to adjust warfarin dosage according to their needs in stead of living on a fixed diet to comply with a fixed medication. Living with anticoagulants has become more demanding than just taking the pills ordered by the doctor. As a patient you need to take responsibility by getting involved. The reward is control of the therapy in contrast to letting the therapy control your life. 

J. Michael Hasenkam MD DMSc
Professor of Experimental Cardiac Surgery
Department of CardioThoracic and Vascular Surgery
Skejby Sygehus, Aashus University hospital
Brendstrugpaardsvej 100
DK-8200 Arhus 

"Living with anticoagulants" World Congress of Cardiology 2006, Barcelona,
Chairpersons: J.M. Hasenkam( Aarhus), C. Schaefer (Ratingen),
Nonprofit Organisation Symposium organized by ISMAAP (International Self-Monitoring Association for oral Anticaogulated Patients)
September 3rd, 2006