藥事照護提升神經內科門診中風病人Warfarin正確用藥認知之成效

The Impact of Pharmaceutical Care on Warfarin Use in Patients with Stroke at Neurology Outpatient Department

研究目的：Warfarin是目前最常用於預防血栓栓塞疾病的口服抗凝血劑。使用warfarin時，需要清楚定義適應症及其相對應的目標治療範圍，並且根據凝血酶原時間或國際標準化比率調整劑量，以提高在目標治療範圍內的時間百分比，降低出血的風險並確保其療效。由於中風病人的獨特性，例如平均年齡較大、自我照顧能力不足、合併使用其他影響warfarin藥效的藥物（如amiodarone、statins），尤其是台灣民間口耳相傳的「通血路」中藥方，皆為可能造成控制warfarin療效困難的原因。為此我們建立跨團隊的warfarin用藥指導模式，在神經內科門診運用當面訪談的方式進行用藥指導，提升病人正確用藥認知，以達到warfarin治療最佳的有效性和安全性。研究材料與方法：自2011年7月1日起至2011年12月31日間，由院內醫療資訊系統篩選出當天神經內科掛號名單中，處方包含warfarin之中風病人。利用病人等候看診的時間，在門診專用空間或於候診區藥師對病人和／或其家屬進行用藥指導。資料收集由專責藥師負責，包含一份認知學習功能量表、一份出血風險量表和一份正確用藥認知量表。病人第二次回診時再次評估正確用藥認知量表，以分析藥師用藥指導對提高warfarin正確用藥認知的成效。研究結果：實行6個月共收案106位中風病人。在藥師用藥指導前約有70%以上病人能辨認、說出warfarin的作用和服用劑量，用藥指導後可達到90%以上；只有不到50%的病人知道服用warfarin需要定期抽血監測PT/INR，用藥指導後可達到80%以上；約有90%的病人不知道服用warfarin時飲食要注意什麼，用藥指導後可降低至30%以下；約有60-70%的病人不知道中草藥和健康食品或其他藥品對warfarin藥效的影響、如何自我防護和監測出血副作用、他處就醫時須主動告知服用warfarin等，用藥指導後可降低至20%以下。研究結論：藥師用藥指導能提高神經內科門診中風病人warfarin的正確用藥認知，確保治療效果並保障用藥安全。

Introduction: Warfarin is a vitamin K antagonist widely used to prevent thromboembolic disease. The safety and effectiveness of warfarin can be optimized by monitoring PT/INR and adjust dose accordingly to maximize the time in therapeutic range. Because patients with stroke tend to have unique characteristics such as old age, lack of self-care capability, presence of drug-drug interactions (e.g. amiodarone and statins) and above all, taking herbal medicine that has anticoagulation effect, which could lead to exaggeration of the effect of warfarin and cause significant hemorrhage. We built a pharmaceutical care model at neurology outpatient department to improve warfarin cognition as well as its therapeutic effectiveness and safety.Methods: From July 2011 to December 2011, patients treated with warfarin who visited our neurology outpatient department were included. A trained pharmacist explained all important information to the patient using a pre-defined checklist. The patients' answers were documented for re-evaluation at next visit. The increase in the rate of correct answer was used to assess the impact of pharmaceutical care on warfarin cognition.Result: A total of 106 patients with stroke treated with warfarin were included. Before instruction about 70% were able to identify warfarin, understand the indication and the dose they were taking, which all increased to above 90% after instruction. Less than 50% were aware of the importance of monitoring PT/INR regularly, which increased to 80% after instruction. More than 90% did not know vegetables rich in vitamin K can decrease the effect of warfarin, which decreased to less than 30% after instruction. More than 60-70% did not know warfarin interaction with many herbal medicine and food supplement, how to self-monitoring bleeding and the importance of telling doctors they were taking warfarin, which decreased to 20% after instruction.Conclusion: Pharmaceutical care can improve warfarin cognition at neurology outpatient department and increase the safety and the effectiveness of warfarin.