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Factors affecting time to maintenance dose in patients initiating warfarin.

ABSTRACT: Patients starting warfarin often experience lengthy dose-titration periods, when they are at high risk for bleeding and thromboembolism. However, relatively little is known about why some patients take longer than others to reach maintenance dose. Thus, we sought to identify social, clinical, and genetic factors associated with prolonged time to maintenance dose (TTM).We conducted a time-to-event analysis, using a prospective cohort of patients initiating warfarin (N?=?390). Additionally, we examined whether changes in post-initiation factors were associated with TTM. Finally, we performed a secondary analysis in a subcohort (N?=?156) assessing the effect of adherence on TTM.No genetic or post-initiation factors were significantly associated with TTM. However, previous use of warfarin [hazard ratio (HR)?=?0.64; 95% confidence interval (CI) 0.46, 0.88], current smoking status (HR?=?0.61; 95%CI 0.39, 0.96), fewer than four doctor's visits in the previous year (HR?=?0.63 vs 4-12 visits; 95%CI 0.46, 0.88), and worse general health status (HR?=?0.63; 95%CI 0.47, 0.84) were significantly associated with longer TTM. Use of illegal injectable drugs (HR?=?2.51; 95%CI 1.17, 5.39) was associated with shorter TTM. On secondary analysis, the HR for better adherence and TTM was 1.70 (95%CI 0.88, 3.27).Time to maintenance dose was associated with pre-existing behavioral factors, health care utilization, and health quality but not clinical comorbidities or genetic factors in patients initiating warfarin. Future studies are needed to determine whether warfarin patients with prolonged TTM would have better outcomes on alternative agents.

SUBMITTER: Finkelman BS

PROVIDER: S-EPMC4570031 | biostudies-literature | 2015 Mar

REPOSITORIES: biostudies-literature

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Factors affecting time to maintenance dose in patients initiating warfarin.

Finkelman Brian S BS French Benjamin B Bershaw Luanne L Kimmel Stephen E SE

Pharmacoepidemiology and drug safety 20141211 3

<h4>Purpose</h4>Patients starting warfarin often experience lengthy dose-titration periods, when they are at high risk for bleeding and thromboembolism. However, relatively little is known about why some patients take longer than others to reach maintenance dose. Thus, we sought to identify social, clinical, and genetic factors associated with prolonged time to maintenance dose (TTM).<h4>Methods</h4>We conducted a time-to-event analysis, using a prospective cohort of patients initiating warfarin ...[more]

PMID: 25504915

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Project description:Oral anticoagulant (OAC) therapy has been the main treatment approach for stroke prevention for decades. Warfarin is the most widely prescribed OAC in the United States, but is difficult to manage due to variability in dose requirements across individuals. Pharmacogenomics may mitigate risk concerns related to warfarin use by fostering the opportunity to facilitate individualized medicine approaches to warfarin treatment (e.g., genome-guided dosing). While various economic evaluations exist examining the cost-effectiveness of pharmacogenomics testing for warfarin, few observational studies exist to support these studies, with even fewer using genotype as the main exposure of interest. We examined a cohort of individuals initiating warfarin therapy between 2004 and 2017 and examined bleeding and cost outcomes for the year following initiation using Mayo Clinic's billing and administrative data, as well the Mayo Clinic Rochester Cost Data Warehouse. Analyses included descriptive summaries, comparison of characteristics across exposure groups, reporting of crude outcomes, and multivariate analyses. We included N = 1,143 patients for analyses. Just over a third of our study population (34.9%) carried a warfarin-sensitive phenotype. Sensitive individuals differed in their baseline characteristics by being of older age and having a higher number of comorbid conditions; myocardial infarction, diabetes, and cancer in particular. The occurrence of bleeding events was not significantly different across exposure groups. No significant differences across exposure groups existed in either the likelihood of incurring all-cause healthcare costs or in the magnitude of those costs. Warfarin-sensitive individuals were no more likely to utilize cardiovascular-related healthcare services; however, they had lower total and inpatient cardiovascular-related costs compared to warfarin-insensitive patients. No significant differences existed in any other categories of costs. We found limited evidence that warfarin-sensitive individuals have different healthcare spending than warfarin-insensitive individuals. Additional real-world studies are needed to support the traditional economic evaluations currently existing in the literature.

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Factors affecting time to maintenance dose in patients initiating warfarin.

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Factors affecting time to maintenance dose in patients initiating warfarin.

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