Clinical Question: Do patients monitor and manage their oral anticoagulation at least as well as professionals?

Setting: Outpatient (any)

Study Design: Meta-analysis (randomized controlled trials)

Synopsis: The investigators searched multiple databases for randomized controlled trials comparing self-monitoring of oral anticoagulation with standard monitoring. They also sought ongoing trials and data from equipment manufacturers in an attempt to find unpublished data. Three reviewers independently assessed each study for inclusion, with discrepancies resolved by consensus. Additionally, they assessed each study’s methodologic quality.

Ultimately, the authors identified 14 studies including 1,309 patients. These were generally small studies with an average of 94 patients. In all studies, the self-monitored patients maintained their International Normalized Ratio within the target range at least as well as those with standard monitoring. More importantly, only 2.2 percent of self-monitored patients had thromboembolic events compared with 4.6 percent receiving standard care (number needed to treat = 43; 95% confidence interval, 27 to 92). In the studies that directly measured major hemorrhage and overall death, these outcomes also were significantly better in the self-monitoring groups.

These results should be used with caution because a high proportion of patients (31 to 88 percent) did not enroll or dropped out because of the complexity of self-management.

Bottom Line: Patients who self-monitor oral anticoagulation have fewer thromboembolic events than those using standard approaches to monitoring; however, self-monitoring should be offered only to literate and motivated patients. Additionally, the machines are costly and not universally covered by insurance. (Level of Evidence: 1a)