Safety and efficacy of warfarin in patients with moderate thrombocytopenia.

INTRODUCTION: Patients with moderate thrombocytopenia and comorbidities requiring anticoagulation are currently sub-optimally treated because of bleeding concerns. Guidance on anticoagulating such patients is currently lacking because of limited data on safety and efficacy of anticoagulation in such patients. METHODS: This retrospective study compared the incidence of bleeding and thrombosis in a cohort of warfarinized patients with sustained platelet counts below 100×109/L against a cohort with normal platelet counts (>140×109/L). Primary outcomes of safety and efficacy were determined by incidence rate ratios (IRR) of bleeding and thrombotic events. International normalized ratio (INR) and platelet counts during adverse events in thrombocytopenic arm were secondary outcomes. RESULTS: 137 thrombocytopenic patients (104,985 patient-exposure days) were compared against 939 normal patients (715,193 patient-exposure days). IRR of minor, major bleeding and thrombosis among thrombocytopenic patients were 3.03 (95% CI: 1.57-5.60), 1.48 (95% CI: 0.44-3.98), and 0.807 (95% CI: 0.09-3.43) respectively. Median INR and platelet count readings during minor and major bleeds were 3.60 (IQR: 2.70-4.12) and 3.12 (IQR: 2.82-4.22), and 99×109/L (IQR: 77.0-147.0×109/L) and 115×109/L (IQR: 107.5-169.5×109/L) respectively. CONCLUSION: Warfarinized thrombocytopenic patients are at higher risk of minor bleeding complications with a higher tendency for major bleeding but derive similar benefits against thrombotic events compared to normal patients. Bleeding events are associated with higher INRs. A narrow INR target with an upper limit below 2.5 together with closer anticoagulation monitoring may improve safety of patients.

The effects of fasting in Muslim patients taking warfarin.

BACKGROUND: Anticoagulation with warfarin is influenced by dietary changes but the effect of fasting on warfarin therapy is unknown. OBJECTIVES: To study changes in international normalized ratio (INR) and the percentage of time within therapeutic range (%TTR) before, during and after the Muslim fasting month (Ramadan) in stable warfarinised Muslim patients. METHODS/PATIENTS: In this prospective study, weekly INR readings were taken at home visits from participating patients during three study periods: before, during and after Ramadan. Readings were blinded to patients and their primary physicians except for when pre-set study endpoints were reached. RESULTS: Among 32 participating patients, mean INR increased by 0.23 (P = 0.006) during Ramadan from the pre-Ramadan month and decreased by 0.28 (P < 0.001) after Ramadan. There was no significant difference (P = 1.000) in mean INR between the non-Ramadan months. %TTR declined from 80.99% before Ramadan to 69.56% during Ramadan (P = 0.453). The first out-of-range INR was seen around 12.1 days (95% CI, 9.0-15.1) after the start of fasting and returned to range at about 10.8 days (95% CI, 7.9-13.7) after Ramadan. Time above range increased from 10.80% pre-Ramadan to 29.87% during Ramadan (P = 0.027), while time below range increased from 0.57% during Ramadan to 15.49% post-Ramadan (P = 0.006). No bleeding or thrombotic events were recorded. CONCLUSIONS: Fasting significantly increases the mean INR of medically stable patients taking warfarin and the likelihood of having an INR above therapeutic targets. For patients maintained at the higher end of INR target ranges or at increased risk of bleeding, closer monitoring or dosage adjustment may be necessary during fasting.

Balloon tamponade for postpartum haemorrhage: case series and literature review.

OBJECTIVES: To audit the use of intrauterine balloon tamponade for the management of massive postpartum haemorrhage and compare outcomes with those documented in the literature. DESIGN: Retrospective case series. SETTING: Obstetric Unit of a regional hospital in Hong Kong. PATIENTS: All cases with severe postpartum haemorrhage from January 2011 to June 2012 in which Bakri intrauterine balloon catheters were used for management. MAIN OUTCOME MEASURE: Successful management with prevention of hysterectomy. RESULTS: A total of 19 cases were identified. The postpartum haemorrhage was successfully treated without the need for additional procedures in 15 patients. Hysterectomy was avoided in a further two cases by recourse to radiologically guided uterine artery embolisation. In two patients, balloon tamponade failed in that hysterectomy was carried out. Thus, the overall success rate of intrauterine balloon tamponade alone was 79%, which was comparable to reported rates in the literature. CONCLUSION: Bakri balloon tamponade is an effective means of managing massive postpartum haemorrhage, and should be adopted in protocols to manage such patients.

Adherence to osteoporosis medications amongst Singaporean patients.

UNLABELLED: Compliance and persistence to bisphosphonates amongst Singaporean patients with osteoporosis were estimated. Mean medication possession ratio (MPR) ± standard deviation (SD) was 78.9 ± 27.5%, and 69.0% was persistent at 1 year. In contrast to US and Europe where poor adherence is noted, our study suggests higher adherence rates to bisphosphonate therapy amongst patients. INTRODUCTION: Adherence to bisphosphonate therapy during treatment of osteoporosis has been reported to be poor. We aimed to estimate the compliance and persistence to prescribed bisphosphonate therapy amongst patients at the largest public restructured hospital in Singapore. METHODS: This is a retrospective analysis of records of patients who were prescribed the two most commonly used oral bisphosphonates-alendronate and risedronate. The study was conducted between January 2007 and December 2008. Prescription and pharmacy refill records of all patients were extracted and matched. Compliance was calculated using the MPR, while persistence, a dichotomous variable, was defined as continuous refill of bisphosphonates for at least 12 months with a permissible gap of 30 days. RESULTS: Seven hundred ninety-eight patients were included in the study. Mean MPR ± SD was 78.9 ± 27.5%, and 69.0% of the patients were persistent with bisphosphonate therapy at 1 year. The proportion of patients with MPR ≥ 80% at 6, 12 and 18 months was 90%, 72% and 62%, respectively. Age <69 years was associated with better compliance (OR, 1.34; 95% CI, 0.99-1.82; P = 0.043), and history of fractures was associated with better compliance (OR, 1.38; 95% CI, 1.02-1.87; P = 0.038) and persistence (OR, 1.33; 95% CI, 0.97-1.82; P = 0.046). CONCLUSION: In contrast to studies conducted in the US and Europe that show poor adherence, our study suggests higher adherence rates to bisphosphonate therapy amongst Singaporean patients.