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June 23/30, 1999

Patient Self-management of Oral Anticoagulation—Reply

Author Affiliations

Margaret A.WinkerMD, Deputy EditorIndividualAuthorPhil B.FontanarosaMD, Interim CoeditorIndividualAuthor

JAMA. 1999;281(24):2283-2284. doi:10-1001/pubs.JAMA-ISSN-0098-7484-281-24-jbk0623

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