Patient use of warfarin drops following first stroke

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PTINR.com Staff

Despite benefit of continuing warfarin for second stroke, study finds a 45% drop is warfarin use.

A Swedish study of 21,077 patients published in the medical journal Stroke¹ found that patients who experienced an initial stroke were less likely to be taking preventative measures 2 years later. Warfarin (Coumadin®*) was the most discontinued preventative medicine despite continued clinical benefit to patients.

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"I think you can make a parallel from this study to other countries as well, because stroke care is built on the same principles in the whole Western world, with a tight connection to healthcare professionals in the first weeks and months and then much less so once patients are out in the community," said Dr Eva-Lotta Glader the chief investigator of the study and stroke unit physician at the Umeå University Hospital in Umeå, Sweden. "We need to have special intervention programs for stroke patients, because some intervention programs have been shown to lead to better persistence rates and better outcomes when it comes to recurrent events."¹

87% of the strokes were determined to be ischemic strokes compared to only 13% hemorrhagic. The persistence of patients taking warfarin (Coumadin ®) was good at 89% in the first four months, however dropped dramatically down to 45% in the 24 months of follow up. Reasons for discontinuation included the difficulty in managing the drug and advanced patient age as it related to patient safety. "Warfarin is the most difficult drug to take and persistence with the drug depends not just on compliance but also on the physician, who may decide that the patient should not continue on the drug because of the risk for adverse events. Advanced age was associated with high persistence of antiplatelet drugs but low persistence of warfarin," study authors add, "[while] poor self-perceived general health and low mood tended to reduce the chance of being a persistent medication user."²

The study found patients were often unaware they needed to take their medications indefinitely. Since warfarin testing results in an INR representing some form of warfarin dosing adherence – physicians hold some responsibility for patients discontinuing preventative treatment.

Home INR testing for patients needing indefinite anticoagulation is a proven method to improve control of warfarin and enhance patient safety.³ This may be of interest to physicians concerned about adverse events in their population. Appropriate candidate selection for home monitoring may be one solution to address the 44% discontinuation seen in this study of real-world compliance of warfarin. Home INR testing is a covered benefit for Medicare patients on warfarin more than 90 days with chronic atrial fibrillation, mechanical heart valves, venous or pulmonary embolism.⁴