Identifying the Risks of Anticoagulation in Patients with Substance Abuse
Authors
Efird, Lydia M.Miller, Donald R.
Ash, Arlene S.
Berlowitz, Dan R.
Ozonoff, Al
Zhao, Shibei
Reisman, Joel I.
Jasuja, Guneet K.
Rose, Adam J.
UMass Chan Affiliations
Department of Quantitative Health SciencesDocument Type
Journal ArticlePublication Date
2013-04-26Keywords
AnticoagulationWarfarin
Alcohol abuse
Drug abuse
Substance abuse
Cardiovascular Diseases
Epidemiology
Health Services Research
Substance Abuse and Addiction
Metadata
Show full item recordAbstract
BACKGROUND: Warfarin is effective in preventing thromboembolic events, but concerns exist regarding its use in patients with substance abuse. OBJECTIVE: Identify which patients with substance abuse who receive warfarin are at risk for poor outcomes. DESIGN: Retrospective cohort study. Diagnostic codes, lab values, and other factors were examined to identify risk of adverse outcomes. PATIENTS: Veterans AffaiRs Study to Improve Anticoagulation (VARIA) database of 103,897 patients receiving warfarin across 100 sites. MAIN MEASURES: Outcomes included percent time in therapeutic range (TTR), a measure of anticoagulation control, and major hemorrhagic events by ICD-9 codes. RESULTS: Nonusers had a higher mean TTR (62 %) than those abusing alcohol (53 %), drugs (50 %), or both (44 %, p < 0.001). Among alcohol abusers, an increasing ratio of the serum hepatic transaminases aspartate aminotransferase/alanine aminotransferase (AST:ALT) correlated with inferior anticoagulation control; normal AST:ALT ≤ 1.5 predicted relatively modest decline in TTR (54 %, p < 0.001), while elevated ratios (AST:ALT 1.50-2.0 and > 2.0) predicted progressively poorer anticoagulation control (49 % and 44 %, p < 0.001 compared to nonusers). Age-adjusted hazard ratio for major hemorrhage was 1.93 in drug and 1.37 in alcohol abuse (p < 0.001 compared to nonusers), and remained significant after also controlling for anticoagulation control and other bleeding risk factors (1.69 p < 0.001 and 1.22 p = 0.003). Among alcohol abusers, elevated AST:ALT >2.0 corresponded to more than three times the hemorrhages (HR 3.02, p < 0.001 compared to nonusers), while a normal ratio AST:ALT ≤ 1.5 predicted a rate similar to nonusers (HR 1.19, p < 0.05). CONCLUSIONS: Anticoagulation control is particularly poor in patients with substance abuse. Major hemorrhages are more common in both alcohol and drug users. Among alcohol abusers, the ratio of AST/ALT holds promise for identifying those at highest risk for adverse events.Source
Efird LM, Miller DR, Ash AS, Berlowitz DR, Ozonoff A, Zhao S, Reisman JI, Jasuja GK, Rose AJ. Identifying the Risks of Anticoagulation in Patients with Substance Abuse. J Gen Intern Med. 2013 Apr 26. DOI 10.1007/s11606-013-2453-x.DOI
10.1007/s11606-013-2453-xPermanent Link to this Item
http://hdl.handle.net/20.500.14038/46653PubMed ID
23620189Related Resources
Link to article in PubMedae974a485f413a2113503eed53cd6c53
10.1007/s11606-013-2453-x