SERIOUS side effects caused by blood-thinning drugs can be slashed with written instructions, according to new research from the United States.

Researchers have found that giving patients written and verbal instruction on drugs with a narrow therapeutic range, like blooding-thinning warfarin, can significantly reduce the number of serious side effects.

Researchers of the study, published in the October issue of the Journal of General Internal Medicine, found a number of factors can reduce the amount of warfarin-related side effects, which include gastrointestinal bleeding and bleeding in the brain.

The study was headed by Associate Professor Joshua Metlay, of the general internal medicine department at the University of Pennsylvania. He is also a senior scholar in the Centre for Clinical Epidemiology and Biostatistics.

Prof Metlay’s team worked in collaboration with the Pennsylvania Pharmaceutical Assistance Contract for the Elderly program. The study revealed doctors, nurses and pharmacists play an important role in limiting patients’ risk of developing warfarin-related bleeding problems.

The researchers studied 2346 elderly patients on warfarin for a variety of conditions including heart rhythm abnormalities, deep vein thrombosis, stroke, heart valve replacements or pulmonary embolism.

Pennsylvania Healthcare Cost Containment Council data was used to determine which of the patients in the study were hospitalised with warfarin-related bleeding problems.

Written instructions the key

Of the patients in the study, the team compared the instructions they were given when prescribed warfarin.

While some patients were given no instructions other than what was on the bottle, the results showed patients who were given written instructions, or written and verbal instructions, were less likely to have a warfarin-related bleeding problem.

“Our study found that verbal communication of medication instructions was not associated with reduced risk of warfarin-related bleeding, but written communication with or without verbal communication was associated with reduced risk,” Prof Metlay said.

“This does pose a challenge for patients with low literacy. However, tools exist to create very low literacy, written, communication guides that might be effective in this setting.”

Communication takes time

Somewhat surprisingly, 45% of subjects said they did not receive any instructions from their healthcare professional.

This led the team to conclude that the rates of complications could be slashed if doctors, nurses and pharmacists improved their communication and gave patients written and verbal instructions on the safe use of the drug.

“Health communication is challenging,” Prof Metlay said.
“It takes time with the patient but time is often tight in primary care practices.
“In addition, until recently, medical education programs had placed little emphasis on skill building in communication despite the central role it plays in health care, but I think that is changing.”

Collaborative approach needed

Along with better communication at the time of being prescribed warfarin by their doctor, patients also reduced their risk of suffering serious bleeding as a side effect of warfarin if they only saw one doctor for their warfarin prescription and only got this filled at one pharmacy.

Study results also revealed patients who received medication instructions from their doctor, nurse as well as pharmacy staff were 60% less likely to develop a serious bleeding problem over the following two years.

This has the added benefit of reducing hospitalisations by avoiding serious bleeding problems.

Communication needed for other drugs

Despite the focus on warfarin in the study, the need for better communication can also apply to other drugs, according to Prof Metlay.

“Warfarin is an example of a drug with a narrow therapeutic index,” he said.

“Other examples include digoxin and certain anticonvulsants, where it is necessary to monitor drug levels to achieve the narrow balance between therapeutic level and toxicity.

“It is probable that the importance of medication instruction communication holds true for these medications as well.

“More broadly, even though it may be less obvious when patients fail to take their other medications as prescribed, our findings may apply to virtually all drugs for which optimal effectiveness depends on good drug-use patterns.”

Universal need

Prof Metlay is confident that while the study was conducted in the US, the results supporting the need for better communication between health care workers and patients can be applied in other countries.

“I think these findings are relatively universal,” he said.

“Regardless of the country, patients and their non-medical caregivers are still responsible for the majority of outpatient medication administration.

“Therefore, improved communication of drug use instructions could prove to be beneficial in many different settings.”

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