Literature Review Sample on Evaluation of the Impact of Pharmacist’s Input into Anticoagulation Therapy Outcomes in Terms of Efficacy and Safety

This study entitled, “An Evaluation of the Impact of Pharmacist’s Input into Anticoagulation Therapy Outcomes in Terms of Efficacy and Safety” is an in depth learning and analysis of the input of pharmacist’s on the improvement of anticoagulation therapy. From the time when heparin and warfarin has become obtainable, the prevention and administration of thromboembolism and the consideration of dosing methods and observation of anticoagulant therapy has constantly evolved. Dager and Gulseth1 claimed that numerous health care professionals have gradually identified the possible advantages of pharmacist input with administering anticoagulant therapy. Additionally, the accessibility of heparin and warfarin for the prevention and management of thromboembolism and the notion on dosing approaches and supervising of anticoagulant therapy has insistently developed.

This study then was aimed at understanding the importance of pharmacist’s input on the improvement of anticoagulation therapy outcomes in an outpatient setting of a tertiary hospital in Saudi Arabia. Guaranteeing the best possible result among patients getting anticoagulant therapy entails a properly-coordinated orderly approach. A developing body of information suggests that executing an anticoagulation management service (AMS) that aids patients to get better clinical outcomes than care offered by their private doctors such as usual care. However, various studies contrasting AMS to usual care was restricted by a comparatively little number of patients, patient populations with limited hints for anticoagulation therapy such as those with mechanical heart valve prosthesis and atrial fibrillation or usual care control groups which takes in medical professionals and other less skilled clinicians.2

Further the Department of Veterans Affairs 3 discussed that long-standing anticoagulation therapy with Vitamin K antagonists such as warfarin has been found to lessen major thromboembolic problems among patients with various chronic circumstances, counting atrial fibrillation, mechanical heart valves, accounts of deep vein thrombosis and pulmonary embolism. Conversely, Vitamin K adversaries covers a much tapered curative window involving frequent laboratory observations to guarantee that patients are neither exceptionally anti-coagulated, that adds to the risk of bleeding, or under anti-coagulated, which enhances the possibility for thromboembolism. Laboratory observations consist of quantifying the blood’s propensity to coagulate with a test identified as the International Normalized Ratio (INR), generally executed every 4-6 weeks.

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In view of the fact that the administration of continuing oral anticoagulation needs frequent examination and dosage adjustment, anticoagulation clinics (ACC) have been developed to restructure and regulate this care.4 Normally managed by personally educated pharmacists or nurses, these clinics offer intense patient education, provide timely follow-up of INR results, use algorithms for dose adjustments, and are easily accessible to patients between visits.5 The California State Board of Pharmacists6 further conferred that optimal administration of anticoagulated patients lessens therapeutic malfunctions and bleeding snags, thereby achieving positive patient results and lessening chances of hospitalizations as well as health care expenses.

Further, the stability between benefits and risks of anticoagulation therapy in reality can be tainted by aspects across three domains: the drug, the patient, and the provider. Even though aspects related with these areas can autonomously influence results, more frequently, it is the multipart interaction of all three that eventually establishes the result of therapy in a given patient.7 Chamberlain, Sageser, Pharm et al.8 findings on their study reveals that reviews of all emergency unit visit and inpatient admittance information found one inpatient admission and two emergency unit visits associated with difficulties on oral outpatient anticoagulation therapy in the anticoagulation clinic group relative to eight inpatient admissions and six emergency unit visits related to complications of outpatient therapy for the customary care group. Examination of unfavorable occasion rates did not distinguish a statistically noteworthy dissimilarity in adverse occasions.

Furthermore, Davies and Lumsden 9 discussed the contraindications of employing these prescriptions are characteristically based on benefit versus risk wherein the favorable use of warfarin prevails within a greater peril of bleeding, the patient cannot be prescribed with warfarin. Disease conditions and procedures included in this contemplation are definite blood disorder, profuse bleeding, and some disorders which causes patients to be more prone to lose blood, and malevolent hypertension. As with all prescriptions, if by occurrence the patient develops allergic reactions to warfarin, there are other options concerning anticoagulation that has to be assessed. Additionally, warfarin is considered teratogenic and cannot be used throughout pregnancy. Patient’s previously on warfarin who are to be scheduled for any sort of procedure or surgery where there is a greater possibility of bleeding, the patient will should seize warfarin for an adequate length of time before the procedure with or without a substitute anticoagulant.

Moreover, the American College of Cardiology Foundations10 confers that at the time when the the only oral anticoagulant obtainable was the Vitamin K antagonist and with its numerous limitations that impelled the beginning of new oral anticoagulants marking the factor Xa (apixaban, rivaroxaban, and edoxaban) or the single coagulation enzymes thrombin (dabigatran) or and provided in fixed amounts with no coagulation monitoring. A review on the results and the pharmacology of clinical tests with a new set of agents in stroke avoidance in atrial fibrillation and derived measures following the severe coronary conditions, presenting a standpoint on their forthcoming integration into medical practice was created.

A coherent categorization of currently existing anticoagulants is dependent on their course of management either parenteral or oral as well as their method of action, either direct or indirect, the objectives of novel anticoagulants for long-standing utilization besides the roundabout thrombin inhibitors which is the low molecular weight heparin [LMWH] and the unfractionated heparin [UFH]), direct thrombin inhibitors combine straightly to thrombin and thwart the formation of fibrin as well as thrombin-mediated commencement of dynamic (F) V, FVIII, FXI, and FXIII. Novel anticoagulant also averts thrombin-mediated establishment of antifibrinolysis, inflammation, platelets, and the anticoagulant protein C/protein S/thrombomodulin lane. Further, the direct parenteral thrombin inhibitors incorporate bivalirudin, argatroban, and hirudin. On the other hand, the direct thrombin inhibitors are pro-drugs that create a dynamic compound competent to directly attach the catalytic spot of thrombin. Moreover, drugs that boards coagulation proteases the constrain of the propagation phase which takes in instruments that obstructs FIXa, for instance the FVIIIa (TB-402), DNA aptamer pegnivacogin, or equally FVa/FVIIIa, co-aspects that are significant for the production of thrombin. The given agents hamper a particular stage in coagulation, at a main variation from VKAs, which blocks several steps for the reason that they diminish the amalgamation of the vitamin K–reliant coagulation dynamics. 7

Finally, similar study conducted by Bungard, Gardner, and Archer et al. 11  reveals that anticoagulation clinics managed by pharmacists in a multidisciplinary setting is not just secure and effectual treatment, but is advanced with deference to the increased anticoagulation organization and the reduced occurrence of thromboembolic measures, and demonstrates a leaning towards inferior rates of hemorrhagic measures. These are significant a health professional wellbeing care circumstance that respects the growth of service constraints of patients as well as physician shortages. The established development in care value and cost savings rationalizes the growth of further AMSs.


  1. Dager, WE, Gulseth, MP. Implementing anticoagulant management by pharmacists in the inpatient setting. 2007. Available from Programs/39/Courses/158/CourseMaterial/Implementing%20Inpatient%20Services-AJHP.pdf
  2. Witt DM, Sadler MA, Shanahan RL et al. Effect of a centralized clinical pharmacy anticoagulation service on the outcomes of anticoagulation therapy. 2005 [cited 2012 May 10]; 127(5). Available from: Chest Journal.
  3. Bungard TJ, Gardner L, Hamilton, PH et al. Evaluation of a pharmacist-managed anticoagulation clinic: improving patient care. 2009. 3(1). Available from: Open Medicine.
  4. Davies MG, Lumsden AB. Contemporary endovascular management, volume 2: venous thromboembolic disease.  Minneapolis, MN: Cardiotext Publishing.
  5. Willey M, Chagan L, Sisca TS et al. A pharmacist-managed anticoagulation clinic: six-year assessment of patient outcomes. 2003. 60, pp. 1033-7. Available from:Am J Health-Syst Pharm.
  6. Caterina RD, Husted S, Wallentin L. ESC  working group on thrombosis—task force on anticoagulants in heart diseaseposition paper. April 2012. 59(16). Available from: Journal of the American College of Cardiology.
  7. Chamberlain MA, Sageser NA, Ruiz D. Comparison of anticoagulation clinic patient outcomes with outcomes from traditional care in a family medicine clinic. January–February 2001 14(1). Available from: JABFP.
  8. Bungard TJ, Ackman ML, Ho G, Tsuyuki RT. Adequacy of anticoagulation in patients with atrial fibrillation coming to a hospital. 2000. 20(9). Available from: Pharmacotherapy.
  9. Ansell JE, Hughes R. Evolving models of warfarin management: anticoagulation clinics, patient self-monitoring, and patient self-management. 1996;132(5). Available from:Am J Heart.


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