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Assessment of Adherence to International Guidelines for Warfarin Initiation Protocol at a Major Tertiary Care Hospital in Riyadh, Saudi Arabia.

Alanoud A.Aleid, Eman Alobary, Nasser Alshehri

Introduction Warfarin is an effective anticoagulant and has been widely used in treating and preventing thromboembolic events in different indications. Warfarin dosing protocols and guidelines were developed to improve therapeutics outcomes and enhance patients’ safety. This research aims to assess the adherence to international warfarin guidelines in terms of using loading doses, monitoring, and adjustments. Materials and Methods It is a prospective observational chart review study, which includes patients who are hospitalized, newly prescribed warfarin, and are older than 16 years of age. Warfarin orders and Pyxis reports were collected and screened for eligibility. Then, patients’ charts were reviewed and data were extracted. The primary outcome was to assess adherence to warfarin initiation protocol. Secondary outcomes were to evaluate the use of other anticoagulant for bridging, assess if anticoagulation charts were filled completely, evaluate patients’ risk of bleeding using Out-patients Bleeding Risk Index (OBRI), and the presence of bleeding events. Results In regard to primary outcome, ninety-six patients were identified for enrollment in this study. Only 10.4% of the patients were given warfarin according to the international protocol in terms of using loading dose, frequent monitoring, and dose adjustment compared to 89.6% who did not adhere to the protocol. All patients who received warfarin as per the protocol achieved INR target within 5 days or less compared to almost half of the patients who did not receive warfarin as per the protocol (100% vs. 52%; p= 0.004). Conclusion In conclusion, a large number of patients did not receive warfarin according to the protocol, by missing either appropriate loading dose, or INR monitoring frequency and dose adjustments. This group of patients needed longer time to achieve the desired INR, which lead to a prolonged hospital stay and medical care. Implementation of warfarin initiation and adjustment protocol, and encouragement of health care providers to adhere to is advised.