REPLY
Prevention of Bleeding in Older Patients Taking Warfarin
Rebecca J. Beyth, MD, MS, and
C. Seth Landefeld, MD
2 October 2001 | Volume 135 Issue 7 | Page 549
IN RESPONSE:
We appreciate the comments of Dr. Spyropoulos and agree that there is compelling evidence of the benefits of specialized programs that coordinate management of anticoagulant therapy over "usual care" (1). In addition to the health benefits, the potential economic benefits of an organized process of care for anticoagulant therapy have been noted (2). Since we did not have a nurse- or pharmacist-managed AMS available at our institution, we cannot make any direct comparisons between our intervention and such a management service.
Regarding Dr. Kajubi's comments, we did not routinely measure hematocrit levels in our study, and the portable monitors we used measured only the INR. As noted in our study and others (3), most anticoagulant-related bleeding is gastrointestinal. Furthermore, occult upper gastrointestinal lesions are often "unmasked" when patients receive anticoagulant therapy (4, 5). In contrast, specific causes of lower gastrointestinal bleeding during anticoagulant therapy are identified less often. Before routinely including fecal occult blood testing in the management of all patients treated with long-term anticoagulant therapy, its potential health and economic benefits should be formally studied.
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Author and Article Information
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Baylor College of Medicine; Houston TX, 77030 (Beyth)
University of California, San Francisco; San Francisco CA, 94118 (Landefeld)
1. Samsa GP, Matchar DB, Goldstein LB, Bonito AJ, Lux LJ, Witter DM, et al. Quality of anticoagulation management among patients with atrial fibrillation: results of a review of medical records from 2 communities Arch Intern Med. 2000;160:967-73. [PMID: 10761962].
2. Lafata JE, Martin SA, Kaatz S, Ward RE. The cost-effectiveness of different management strategies for patients on chronic warfarin therapy J Gen Intern Med. 2000;15:31-7. [PMID: 10632831].
3. White RH, McKittrick T, Takakuwa J, Callahan C, McDonell M, Fihn S. Management and prognosis of life-threatening bleeding during warfarin therapy. National Consortium of Anticoagulation Clinics Arch Intern Med. 1996;156:1197-201. [PMID: 8639014].
4. Wilcox CM, Truss C. Gastrointestinal bleeding in patients receiving long-term anticoagulant therapy Am J Med. 1988;84:683-90. [PMID: 3261126].
5. Tabibian N. Acute gastrointestinal bleeding in anticoagulated patients: a prospective evaluation Am J Gastroenterol. 1989;84:10-2. [PMID: 2783528].
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