The warfarin clinic receives their patients from referrals. Currently the anticoagulation pharmacists only work with the neuro and cardiovascular departments. Most of the patients that are referred to the clinic are either new start patients or are patients that have uncontrolled INRs.
As a intern pharmacist, I worked in Kaiser's Anticoagulation Clinic so I was really excited to be able to see the differences in anticoagulation therapy between Taiwan and the US. Unlike in US where we have multiple doses of warfarin (1 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg, and 10 mg), at NTUH, they only have the 1 mg tablet and the 5 mg tablet. According to the pharmacist, Asians are often smaller and have a higher risk of bleeds in comparison to other ethnicities so often times higher doses are not necessary. When I asked the inpatient pharmacy supervisor about this, she mentioned that from the inpatient pharmacy's perspective, having less doses available will decrease the chances of medication errors. Because of this, most drugs are only available in two different doses because of the high prescription load and since the pharmacists are doing all of the filling.
Another interesting aspect is how the pharmacists approach dietary questions. As you may know, warfarin has many drug drug interactions and drug food interactions. While the green leafy vegetables are generally similar from country to country, there are certain foods that Taiwanese people eat that we do not eat as often in the US. A great example of this are animal organs (intestines, liver, heart, etc) and blood products (pig's blood), which contains a lot of vitamin K. We don't eat these items too often in the US, but in Taiwan it is a commonly found food, especially in the night markets! Also, people in Taiwan drink a lot of green tea, which contains vitamin K as well. Patients are told that if it's just the brewed green tea, then it is okay to drink it if you are on warfarin. However, the tea leaves itself are a different story and INR should be monitored closely.
Finally, because of the increased risk of bleeds in Asians, they have different therapeutic INR ranges for certain indications as well. Please see the chart below to see the differences in INR goals between Taiwan and the United States.
Targeted INR Goals
|
United States
|
Taiwan
|
Atrial Fibrillation
|
2-3
|
1.5-2.5
|
Atrial Flutter
|
2-3
|
1.5-2.5
|
Ischemic Stroke or TIA due to Afib
|
2-3
|
1.6-2.6
|
Venous Thromboembolism
|
2-3
|
1.8-2.4
|
Mechanical Aortic Valve
|
2-3
|
2-3
|
Mechanical Mitral Valve
|
2.5-3.5
|
2.5-3.5
|
Bioprosthetic Mitral Valve
|
2-3
|
2-3
|
Warfarin Clinic
the 2 tablet strengths available
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