OC 60.5 - Comparative effectiveness of warfarin management strategies: A systematic review and network meta-analysis

Tuesday, June 25, 2024

15:45 – 16:00 ICT

Room: Plenary Hall

Presenting Author(s)

Kansak Boonpattharatthiti, PharmD

PharmD
1. The Research Unit of Evidence Synthesis (TRUES), Faculty of Pharmaceutical Sciences, Naresuan University, Phitsanulok, THAILAND 2. Faculty of Pharmaceutical Sciences, Burapha University, Chon buri, THAILAND
Muang Phitsanulok, Phitsanulok, Thailand

Co-Author(s)

WK

Warittakorn Kategeaw

Graduate Research Assistant
Department of Pharmacotherapy, University of Utah College of Pharmacy, Salt Lake City, UT, USA
Salt Lake City, Utah, United States
HH

Heeseung Hong

PharmD
Department of Pharmacotherapy, University of Utah College of Pharmacy, Salt Lake City, UT, USA
Salt Lake City, Utah, United States
TD

Teerapon Dhippayom

PharmD, PhD
The Research Unit of Evidence Synthesis (TRUES), Faculty of Pharmaceutical Sciences, Naresuan University, Phitsanulok, THAILAND
Muang Phitsanulok, Phitsanulok, Thailand
NC

Nathorn Chaiyakunapruk

Professor
Department of Pharmacotherapy, University of Utah College of Pharmacy, Salt Lake City, UT, USA
Salt Lake City, Utah, United States
DW

Daniel M Witt

PharmD
Department of Pharmacotherapy, University of Utah College of Pharmacy, Salt Lake City, UT, USA
Salt Lake City, Utah, United States

Background: Warfarin plays a crucial role in preventing and treating thromboembolic (TE) disorders. The management of warfarin therapy presents a clinical challenge due to its narrow therapeutic index.

Aims: To assess comparative effectiveness of different warfarin management strategies.

Methods: We searched PubMed, Embase, Cochrane CENTRAL, CINAHL, and EBSCO Open Dissertation through August 2023. We included randomized controlled trials that compared the following interventions: patient self-testing (PST), patient self-management (PSM), anticoagulant management services (AMS), and usual care (UC) in patients prescribed warfarin for any indication. We assessed the risk of bias using the Cochrane Effective Practice and Organization of Care Group (EPOC) risk of bias tool. Risk ratios (RR) with 95% confidence interval (CI) were estimated using frequentist network meta-analyses with a random-effects model. We also conducted sensitivity analyses by excluding small trials ( < 25th percentile of sample size) and trials with high risk of bias. We used surface under the cumulative ranking curve (SUCRA) to rank different warfarin management strategies. This study was registered with PROSPERO (CRD42023491978)

Results: Of the 2,583 articles identified, we included 28 trials involving 8,033 participants (mean age range was 48.5-74.7 years). Most included trials were classified as having an unclear risk of bias (12/28) or a low risk of bias (11/28). PSM is the only intervention that significantly reduces the risk of major TE events compared with usual care (RR 0.41; 95%CI: 0.24-0.71), see Table 1. This finding corresponds with the highest SUCRA of 97.5%. Sensitivity analyses further confirm PSM's robust benefits in reducing TE events. The effects on the following outcomes did not differ across various strategies: all-cause mortality, major bleeding, stroke, transient ischemic attack, and hospitalization.

Conclusion(s): Current evidence indicates that PSM reduces the risk of major TE events and should be considered where appropriate. Other clinical impacts of various warfarin management strategies were not significantly different.