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Word of the Day

Anticoagulation self-monitoring and self-management is a safe option

Clinical Question:
Is self-monitoring and self-management of anticoagulation safe and effective?

Bottom Line:
In (highly) selected patients needing anticoagulation, self-monitoring is associated with fewer venous thromboembolic events (VTEs) and no increased risk of bleeding or death. (LOE = 1a)

Reference:
Heneghan C, Ward A, Perera R, et al. Self-monitoring of oral anticoagulation: systematic review and meta-analysis of individual patient data. Lancet 2012;379(9813):322-334.  [PMID:22137798]

Study Design:
Meta-analysis (randomized controlled trials)

Funding:
Government

Setting:
Various (meta-analysis)

Synopsis:
These authors searched several databases and clinical trials registries to identity 11 randomized trials with approximately 6500 patients (average 2 years of follow-up). They defined "self-monitoring" as self-reporting (self-testing) and self-management (self-testing and self-dosing). Two researchers independently extracted the data with discrepancies resolved by consensus. In addition to searching for unpublished studies, the authors also formally assessed the potential for publication bias and found none. Nearly half the data came from a single Veterans Administration study in which the control group used an anticoagulation clinic. The self-monitored patients were approximately 1.5 years younger than the control patients. Approximately one half of the patients had atrial fibrillation and one third had mechanical heart valves. In 4 of the trials, primary care was the comparator; another 4 used anticoagulation clinics as the comparator. Overall, the rate of VTEs increased over time; the overall event rate reached approximately 20% in 5 years. The self-monitored patients had fewer VTEs. Only 78 patients (95% CI, 55 - 253) would need to self-monitor for 1 year to have one fewer VTE. By 5 years, the number needed to treat dropped to 27 (19 - 87). On the other hand, there was no difference in the rate of major bleeding or deaths. The authors speculate that true self-monitoring (self-testing and self-dosing) is superior to merely self-testing and reporting. Although not directly assessed, one might imagine that the patients included in these studies were likely to be literate, motivated, and teachable.

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