Margaret A.WinkerMD, Deputy EditorIndividualAuthorPhil B.FontanarosaMD, Interim CoeditorIndividualAuthor
In Reply: Drs Li and Tosiello
point out that a teaching program for patients receiving oral
anticoagulation without INR self-monitoring and patients'
self-adjustment of coumarin dosage may also improve treatment results.
To our knowledge, there are no trials comparing the effect of education
programs with and without self-management of anticoagulation. However,
in diabetic patients it has been clearly shown that education programs
will not lead to an improvement in blood glucose control unless
adequate training in blood glucose self-monitoring and self-adjustment
of insulin treatment is also included.1 Of greatest
importance, in our study the major improvement in quality of life was
closely linked to patients' ability to self-monitor and self-manage
treatment. The objective of our study was to investigate the effect of
patients' self-management of oral anticoagulation. Of course,
self-management of anticoagulation therapy can only be safely performed
if it is combined with extensive information and effective patient
training. Therefore, to investigate the effect of self-management of
anticoagulation on the quality of anticoagulant therapy, we had to
include an appropriate patients' education program. Our program does
not include fixed algorithms for the adjustment of the coumarin dosage.
The optimal coumarin dosage adjustment differs greatly from patient to
patient. Therefore, instead of teaching fixed algorithms, several
examples of dosage adjustment were discussed with the patients. Thus,
the patients were encouraged to find their own best individual method
of dosage adjustment based on self-monitoring. There is a lack of valid
data on the effects of using algorithms in the management of
anticoagulation. However, in insulin-treated diabetic patients, fixed
algorithms, or so-called sliding scales, have shown to provide no
benefit or have even proved to be harmful.2
Sawicki PT. Patient Self-management of Oral Anticoagulation—Reply. JAMA. 1999;281(24):2283–2284. doi:10-1001/pubs.JAMA-ISSN-0098-7484-281-24-jbk0623
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