Cochrane for Clinicians
Putting Evidence into Practice
Self-Monitoring and Self-Management of Oral Anticoagulation
Am Fam Physician. 2017 Jun 1;95(11):700-701.
Author disclosure: No relevant financial affiliations.
Does self-monitoring or self-management improve the safety, effectiveness, and feasibility of long-term oral anticoagulation therapy compared with traditional monitoring?
In patients taking warfarin (Coumadin) for anticoagulation, there is moderate-quality evidence that both self-monitoring (number needed to treat [NNT] = 100) and self-management (NNT = 53) reduce thromboembolic events, and that self-management reduces all-cause mortality (NNT = 67). There is low- to moderate-quality evidence that neither self-management nor self-monitoring reduces major or minor hemorrhage. Physicians should consider self-management or self-monitoring for patients who are willing and able to use these strategies.1 (Strength of Recommendation: A, based on consistent, good-quality patient-oriented evidence.)
Portable point-of-care (POC) devices for monitoring long-term oral anticoagulation have been available since the 1990s. Self-monitoring is a strategy in which the patient can measure his or her international normalized ratio (INR) with a POC device, then adjust warfarin dosing by calling a clinic for advice. Self-management strategies refer to patient use of a POC device to measure the INR and adjust warfarin dosage according to a predetermined schedule on physician-approved algorithms. Advantages of both strategies may include patient convenience, ease of monitoring, and fewer thromboembolic complications. A 2006 study suggested that self-monitoring and self-management are cost-effective strategies for those receiving long-term oral anticoagulation.2
A previous version of this review found that use of POC devices by patients for self-monitoring or self-management of anticoagulation improved all-cause mortality, rates of venous thromboembolism, and rates of minor hemorrhage. Self-monitoring also improved rates of major hemorrhage.3
In updating this Cochrane review, the authors found 10 new trials with 4,227 additional patients to bring the aggregate to 28 randomized controlled trials including 8,950 participants.1 The authors assessed risk of bias as low to moderate because blinding participants to allocation was not possible. Studies lasted from three months to nearly five years.
Using this larger body of literature, the authors found that when compared with standard care, self-monitoring of anticoagulation reduced thromboembolic events (absolute risk reduction [ARR] = 1%; 95% confidence interval [CI], 0.1% to 1.8%; NNT = 100 [95% CI, 56 to 1,000]), whereas self-management of anticoagulation reduced thromboembolic events (ARR = 1.9%; 95% CI, 1.1% to 2.4%; NNT = 53 [95% CI, 42 to 91]) and all-cause mortality (ARR = 1.5%; 95% CI, 0.5% to 2.1%; NNT = 67 [95% CI, 48 to 200]). The authors also found a greater reduction in thromboembolic events for patients with atrial fibrillation compared with those who had mechanical heart valves and self-monitored or self-managed anticoagulation therapy. The larger evidence base (with the inclusion
REFERENCESshow all references
1. Heneghan CJ, Garcia-Alamino JM, Spencer EA, et al. Self-monitoring and self-management of oral anticoagulation. Cochrane Database Syst Rev. 2016;(7):CD003839....
2. Regier DA, Sunderji R, Lynd LD, Gin K, Marra CA. Cost-effectiveness of self-managed versus physician-managed oral anticoagulation therapy. CMAJ. 2006;174(13):1847–1852.
3. Garcia-Alamino JM, Ward AM, Alonso-Coello P, et al. Self-monitoring and self-management of oral anticoagulation. Cochrane Database Syst Rev. 2010;(4):CD003839.
4. Sharma P, Scotland G, Cruickshank M, et al. The clinical effectiveness and cost-effectiveness of point-of-care tests (CoaguChek system, INRatio2 PT/INR monitor and ProTime Microcoagulation system) for the self-monitoring of the coagulation status of people receiving long-term vitamin K antagonist therapy, compared with standard UK practice: systematic review and economic evaluation. Health Technol Assess. 2015;19(48):1–172.
5. Heneghan C, Ward A, Perera R, et al. Self-monitoring of oral anticoagulation: systematic review and meta-analysis of individual patient data [published correction appears in Lancet. 2012;379(9821):1102]. Lancet. 2012;379(9813):322–334.
6. Kearon C, Akl EA, Comerota AJ, et al. Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines [published correction appears in Chest. 2012;142(6):1689–1704]. Chest. 2012;141(2 suppl):e419S–e494S.
7. You JJ, Singer DE, Howard PA, et al. Antithrombotic therapy for atrial fibrillation: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 suppl):e531S–e575S.
8. National Institute for Health and Care Excellence. Atrial fibrillation and heart valve disease: self-monitoring coagulation status using point-of-care coagulometers (the CoaguChek XS system and the INRatio2 PT/INR monitor). NICE diagnostics guidance [DG14]. September 2014. http://www.nice.org.uk/guidance/dg14. Accessed August 30, 2016.
9. National Institute for Health and Care Excellence. Venous thromboembolic diseases: diagnosis, management and thrombophilia testing. NICE clinical guideline [CG144]. Updated November 2015. http://www.nice.org.uk/guidance/CG144. Accessed August 30, 2016.
These are summaries of reviews from the Cochrane Library.
This series is coordinated by Corey D. Fogleman, MD, Assistant Medical Editor.
A collection of Cochrane for Clinicians published in AFP is available at http://www.aafp.org/afp/cochrane.
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