By

Huston Powell, R.Ph., M.B.A.

An editorial assignment submitted in partial fulfillment of the requirements for the degree of Doctor of Pharmacy from The University of Illinois at Chicago in cooperation with the University of Colorado.

Life altering changes for patients are required when warfarin therapy is started. Monitoring of blood clotting time is required and attention to prescription and non prescription medication, diet and activity can profoundly influence the patient’s view of their body and the world around them Adherence to prescribed therapy and monitoring can alter a patients life perspective. Non-compliance with therapy and lack of attention to monitoring can reflect a negative change in the mind of patients.

Patients on warfarin therapy are advised from the first dose of the potential hazards associated with warfarin therapy. The concepts of drug bioavailability and the importance of adherence to dosing schedules and monitoring signal a new chapter in the lives of patients at risk of thromboembloism.

Thrombocytopenia during pregnancy can be common, especially in the third trimester. Regardless of the cause, the result can be preeclampsia (in 15-20% of cases) or eclampsia (in 40-50% of cases) For the pregnant woman with a clotting disorder prescribed warfarin the joy and anticipation of pregnancy turn into worry and concern for the newborn and the mother’s own safety. While most clinical signs, including Thrombocytopenia, usually resolve promptly after delivery, the event can profoundly influence the woman’s perception of her pregnancy. How do you quantify the risk for the expectant mother?

The patient with atrial fibrillation on coumadin must coordinate daily activity with the administration of warfarin and concerns for a perceived loss of independence. Patients that are newly diagnosed with AF may be struggling with a combination of Calcium channel antagonists and beta-adrenergic antagonists to control their ventricular heart rate. The concept of anticoagulation for prophylaxis from stroke may be terrifying. Cardiogenic embolism accounts for approximately 20% of strokes.

Atrial fibrillation secondary to valvular heart disease historically has been recognized as a significant risk factor for stroke. Atrial fibrillation patients with a history of rheumatic valvular disease have a 17 fold higher incidence of stroke than in matched controls. Patients with valvular atrial fibrillation require chronic, low intensity anticoagulation with warfarin to prevent thromboembolism and stroke.

The most prevalent site of embolization is the cerebral arterial system resulting in either asymptomatic cerebral infarction or stroke with potentially devastating neurological and functional impairment. Imagine the frustration of a 19-year-old patient two years post stroke. Consider her loss of mobility and loss of independence. Her desire to date and please her boyfriend may be manifested as a loss of intimacy. Imagine her despair that comes from her doctor who refuses to provide any hope for the future. For this child, after her discharge from the hospital her first priority was to fill her prescription for warfarin and begin the pain staking process of trying to regulate her blood’s clotting time.

What passes through the mind of the patient who is post M.I.? The patient must cope with initiation of warfarin therapy and changes in diet and activity levels. All compounded with the need for multiple prescriptions for medications with a myriad of side effects and the need to monitor INR’s and clotting times. The impact of a near death experience that may have accompanied the heart attack and the impending test of the patients desire to live and participate in family and society.

Caregivers try to explain to patients newly prescribed warfarin therapy that thrombosis is the process involved in the formation of a fibrin blood clot. Both platelets and a series of coagulant proteins contribute to clot formation. An embolus is a small part of a clot that breaks off and travels to another part of the vascular system. Damage is caused when the embolus becomes trapped in a small capillary causing ischemic or infarction of the surrounding tissue. Normal clot formation maintains the integrity of the vasculature in response to injury but pathologic clotting can occur in a variety of clinical settings. Abnormal thrombotic events include deep venous thrombosis (DVT) and its primary complication, pulmonary embolism (PE)

Consider that one 2-year old patient with an artificial valve that takes warfarin following placement of an artificial valve. For this child initiation of warfarin therapy has been a simple way of life. No sense complaining about frequent trips to the doctor and clinics for monitoring and her desire to enjoy the company of her 5 year old sister. Playing dolls around the house and rough housing are simply carried out under the watchful eye of her mother who is always afraid the child will fall or bruise herself and bleed. Mom’s daily reminder of her child’s gift of life is the warfarin pill and visits to the anti-coagulation clinic.

Warfarin therapy’s risk may seem irrelevant to the patient with a newly diagnosed deep vein thrombosis who fears that a clot will end their life prematurely. Warfarin therapy is just a reminder of disease to the patient newly Diagnosed with Systemic Lupus Erythamatois (SLE). Diagnosis of SLE alone may be perceived as a life or death sentence. Wafarin therapy and the threat of a life ending blood clot accompany significant changes in their muscle tone and mobility. This patient may be especially at risk of depression and may need psychological or social support. Support of family and caregivers is essential for successful long-term therapy. Initiation of warfarin may be the signal most identifiable drug therapy event that takes place in the mind of the patient with SLE. These patients may feel completely helpless and totally afraid of therapy.

No matter whether patient are aware they are at risk of a blood clot or thrombolic event or development of a clot is a complete surprise, it is often the prescription medication, warfarin that is their constant reminder that they are at risk. Perhaps they learn to value their own lives more; perhaps they can find it easier to appreciate time spent with family and friends or their freedom to be active and alive.

It’s important to emphasize the positive for patient’s taking warfarin. Don’t encourage them to sit around and feel sorry for themselves. It is more constructive to help patients decide, "okay, I have to take this medicine, every day, exactly as prescribed and I will work with my physician or pharmacist to adjust my therapy to accommodate my life.

Just looking at many patients who must take warfarin for the rest of their lives, it is difficult to imagine some were ever sick. They do not live recklessly and without constraints. They have simply decided that life with warfarin therapy is better than without it. Their daily consumption of their warfarin is not a sad thing, it’s just a simple reminder of how valuable and special life really is.

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