This is a guest blog by Danielle Pouletsos. She completed her BS in Health Science with a concentration in Public Health and Community Health Education in 2005. She earned her Master of Public Health degree at the University of Illinois at Chicago and specialized in Public Health Informatics in 2009. She has worked in the non-profit sector for over 10 years serving those with HIV/AIDS and Developmental Disabilities.
Read more about public health, mhealth and related topics on Danielle’s blog.
This is part 1 of a two part series that explores the real world impact of mHealth.Part I – The Hassle of Anticoagulation Management
Warfarin, or Coumadin, is the most widely prescribed anticoagulant and has been on the pharmaceutical market for about 60 years. Anticoagulation therapy saves many lives each year, but also poses extreme health risks from side effects, mismanagement, and birth defects. Termed a “blood-thinner,” Warfarin inhibits the production of Vitamin K in the body, which is essential for the body’s natural blood clotting cascade. There are a variety of diagnoses that will influence practitioners to decide whether or not to place a patient on anticoagulation therapy, either for short term, or chronic use. There are also multiple diagnoses in which Warfarin therapy is the patient’s only option.
Hundreds of thousands of people are prescribed Warfarin. Among these people, their diagnoses range from congenital heart defects, valve disorders (natural or artificial), irregular heart rhythms, and a history of stroke. These are not the only conditions that would require a patient to receive anticoagulation therapy, but they are the most common. People diagnosed with autoimmune and genetic clotting disorders are less common, but also require such therapy.
A patient suffering from deep-vein thrombosis (DVT), a pulmonary embolism, or a blood clot located anywhere in the body will most likely receive Warfarin therapy until the clot resolves and absorbs back into the body. This process can take months and requires very close monitoring. Warfarin has many benefits, but it also has side effects that can be fatal if not properly managed. Each year a patient is on Warfarin therapy, the chance of having a fatal bleed increases by 1%. That may not sound like much of a risk, but younger patients who are on chronic anticoagulation therapy can easily live decades while receiving said therapy. For example, a young patient who is on chronic Warfarin therapy for 40 years has a 40% chance of a fatal bleed. The stakes are much higher now. How do I know all of this? Because I am one of those patients. I chose to disclose my own personal health information to give a personal example of the benefits and difficulties of anticoagulation therapy.
The pharmaceutical industry has placed new “blood-thinners” on the market: Xarelto, Pradaxa, Eliquis and Savaysa. The purpose of these blood-thinners is to prevent stroke from atrial fibrillation (the main diagnosis causing patients to be on Warfarin therapy). They do not have all of the benefits Warfarin does, but they also do not require regular monitoring, which is a heavily advertised benefit along with the freedom to eat foods containing vitamin K without limitations, which is a major con for patients undergoing Warfarin therapy. Patients can eat foods containing vitamin K while on Warfarin therapy, but the amount has to be consistent each week for Warfarin therapy to be effective. These new blood-thinners make anticoagulation therapy “easier” and less of a “hassle” for patients. Should there be an incident of major bleeding, either external or internal, there is an “antidote” available for Warfarin; vitamin K, which takes hours to have an effect. Or, if the bleeding incident is urgent, plasma containing clotting factors can be used. The FDA recently approved an antidote to Pradaxa in the event of severe bleeding, but no such antidote is available for the other three aforementioned medications.
Warfarin therapy requires close and regular monitoring. Depending on the patient, there will be a target INR (International Normalized Ratio), in simpler terms…how thin your blood is. Typically, patients are given the INR range of 2.0-3.0. Depending on the reasons people are prescribed Warfarin therapy, the effective INR range can also be 1.5-2.5, or 2.5-3.5. The higher the number, the “thinner” the blood and the longer it takes to clot.
Patients have to either go to a lab regularly, or go to a facility, a Coumadin Clinic, that specializes in the management of Warfarin therapy. Patients who go to a lab to have their blood drawn usually have to wait two to three days to get their results. If the said patient’s INR is too low or too high, which poses great health risks either way, waiting two to three days can negatively affect patient outcomes. In addition to the lab result waiting period, Warfarin also has a delayed affect, for example, the dose taken on a Monday will not impact one’s INR until Wednesday or Thursday. The availability of Coumadin Clinics is sparse, but a patient will know their INR results within seconds. There is a device made by Roche Diagnostics that can test someone’s INR with a stick of a finger and a drop of blood placed in a test strip, similar to the process of blood sugar testing, but the machine and its test strips have a high cost. Some insurance companies will cover the cost of the machine for patients whose practitioners are comfortable with them monitoring themselves at home and calling in their results. There are negative consequences that can result because of this. Just giving the provider an INR result and adjusting Warfarin dosage solely based on that does not take into account all of the variables that effect the efficacy of anticoagulation such as medication changes, food intake, and current health status. Depending on the stability of an INR, patients can go up to four weeks without having their INR checked.
It sounds simple, but Warfarin therapy is anything but. Vitamin K levels are easily affected by food choices, medication interactions, illnesses (i.e., a bacterial infection), how hydrated a patient is, and comorbidities. Dark leafy greens are the most common source of vitamin K a patient will eat. Other sources of vitamin K are soy products, canola oil, soybean oil, beans, green tea, daily multivitamins, and herbal supplements to name a few. Foods containing vitamin K will make your blood “thicker” and lower the INR, which if too low, poses a risk for stroke. There are also foods that make the blood “thinner” and can pose a risk of bleeding. Turmeric, cranberry juice and alcohol are just a few.People with autoimmune disorders such as APLS (antiphospholipid syndrome), can have their INR affected simply from a “flare” of the illness. APLS attacks the clotting proteins in the blood and can cause it to be too “thick” or too “thin.” APLS is unpredictable and by the time a “flare” is symptomatic, the blood is already affected. APLS also causes migratory joint pain and the amount of inflammation in the body can affect the INR as well. I suffer from APLS, genetic thrombophilia, non-infective thrombotic endocarditis, arrhythmia, and have a history of DVT and stroke. I had an APLS flare and was admitted into ICU with internal bleeding and was in hypovolemic (hemorrhagic) shock. Two weeks later, it was suspected I had a TIA (transient ischemic attack, or mini-stroke). One extreme to another caused by factors out of my control because of an autoimmune disorder.
Patients on Warfarin therapy need closer, more in-depth monitoring and Roche Diagnostics has come up with a way to do that by joining with the rapid growth of mHealth.To be continued with Part II – The Positive Impact of mHealth on Anticoagulation Therapy