Self-management of oral anticoagulant therapy: A systematic review and meta-analysis
Introduction
Oral anticoagulant therapy with coumarin derivates is prescribed as prevention and treatment to patients with an increased risk of thromboembolism [1]. Since oral anticoagulant therapy increases the risk of bleeding, the therapy requires a careful attention to the balance between the risks of these two outcomes.
Oral anticoagulant therapy is conventionally monitored by laboratory analysis of the international normalized ratio (INR) on plasma obtained by venipuncture. Based on the INR value, health care providers determine the appropriate dosage of coumarin.
Self-management of oral anticoagulant therapy in which highly selected patients analyzes a drop of blood using a portable coagulometer and uses the displayed INR-value for coumarin dosage has over the last years gained interest and is now widely used in routine settings. However, findings from randomized controlled trials that have evaluated the efficacy of self-management compared to conventional management have been inconsistent and the scientific basis for implementing self-management has therefore been debated.
A systematic review [2] and a meta-analysis [3] on the efficacy of self-management of oral anticoagulant therapy are available. However, these papers did not include the most recent trials and did not assess the methodological quality of the included trials [4]. An updated systematic review and a subsequent meta-analysis are needed in order to further evaluate the efficacy and safety of self-management.
Section snippets
Study identification
We searched The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2005, issue 4) and PubMed (start 1951 to December 2005). The search was supplemented by a review of personal files and hand search of published reviews. No language restriction was applied. The following strategy was used to search the CENTRAL and adapted appropriately for the PubMed: ((((“4-hydroxycoumarins” [MeSH]) OR (acenocoumar* OR sinkumar OR sinthrome OR sintrom OR mini-sintrom OR syncoumar OR
Data extraction
Disagreement was present between the two reviewers regarding 32% of the extracted data, but consensus was reached in all cases.
Description of studies
Ten trials comparing self-management to conventional management with a total of 2724 patients were included (Fig. 1 and Table 1) [7], [8], [9], [10], [11], [12], [13], [14], [15], [16]. A description of the included studies is displayed in Table 1.
The included studies had a substantial inter-study variation, e.g., in terms of follow-up, number of patients, INR-interval
Discussion
We found that highly selected patients performing self-management had a reduced risk of death, major complications and spent an increased proportion of time within therapeutic INR target range compared to patients in conventional management. No clear difference in the risk of minor complications was found. There was substantial heterogeneity regarding two of the outcomes (minor complications and time within therapeutic INR target range).
The trials included were all (except two) ranked as lower
Acknowledgements
The secretaries, Linda Nielsen and Marianne Maegaard, RN from the Department of Cardiothoracic and Vascular Surgery, are thanked for their help in conducting this study.
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