Pharmacist-Managed Anticoagulation Services for Warfarin Management in Tertiary Hospitals: The Egyptian Experience


Pharmacist-managed anticoagulation services
Anticoagulation clinic
Therapeutic drug monitoring




Background: Warfarin is widely regarded as the main anticoagulant in lowering the risk of thromboembolism. This study used indicators to compare pharmacist-managed anticoagulation services, using a well-prepared protocol, with physician-managed anticoagulation services. Methods: A retrospective prospective pilot study was conducted to compare patient outcomes before and after transitioning patients to pharmacist-managed anticoagulation services, comparing the proportion of those with therapeutic international normalized ratio (INR), subtherapeutic INR, and supratherapeutic INR, as well as their bleeding occurrences as indicators of assuring quality care. Results: A significant improvement in anticoagulation management was noted in the transition to pharmacist-managed anticoagulation services. The proportion of those with subtherapeutic INR decreased from 61.8% to 11.8% (p < 0.001), those with supratherapeutic INR decreased from 20.6% to 2.9% (p < 0.001), those with therapeutic INR increased from 17.6% to 85.3% (p < 0.001), and the occurrence of bleeding decreased from 11.8% to 0.0%, without significant difference in warfarin doses (median from 4 before the transition to 5 after); in addition, the time to reach therapeutic INR decreased from 12-24 weeks to 2-8 weeks after transitioning to pharmacist-managed anticoagulation services. Conclusion: Pharmacist-managed anticoagulation services are considered safer and more effective than physician-managed anticoagulation services alone in terms of patients’ adherence and satisfaction, which provide an excellent opportunity for quality assurance care.


Pirmohamed M, 2006, Warfarin: Almost 60 Years Old and Still Causing Problems. Br J Clin Pharmacol, 62(5): 509.

Oake N, Jennings A, Forste AJ, et al., 2008, Anticoagulation Intensity and Outcomes Among Patients Prescribed Oral Anticoagulant Therapy: A Systematic Review and Meta-Analysis. CMAJ, 179(3): 235-244.

Landefeld CS, Beyth RJ, 1993, Anticoagulant-Related Bleeding: Clinical Epidemiology, Prediction, and Prevention. Am J Med, 95(3): 315-328.

Kuruvilla M, Gurk-Turner C, 2001, A Review of Warfarin Dosing and Monitoring. Proc (Bayl Univ Med Cent), 14(3): 305-306.

Hamrah MS, Hamrah MH, Hamrah MH, et al., 2019, An Overview of Anticoagulants. CPQ Medicine, 6: 3.

Yimer NS, Abiye AA, Hussen SU, et al., 2021, Anticoagulation Control, Outcomes, and Associated Factors in Patients with Atrial Fibrillation Receiving Warfarin at Tertiary Care Hospital in Ethiopia. Clin Appl Thromb Hemost, 27: 10760296211049786.

Sylvester KW, Ting C, Lewin A, et al., 2018, Expanding Anticoagulation Management Services to Include Direct Oral Anticoagulants. J Thromb Thrombolysis, 45(2): 274-280.

Schmidt GA, Girard TD, Kress JP, et al., 2017, Liberation from Mechanical Ventilation in Critically Ill Adults: Executive Summary of an Official American College of Chest Physicians/American Thoracic Society Clinical Practice Guideline. Chest, 151(1): 160-165.

Holbrook A, Schulman S, Witt DM, et al., 2012, Evidence-Based Management of Anticoagulant Therapy: Antithrombotic Therapy and Prevention of Thrombosis: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest, 141(2): e152S-e184S.

Tran HA, Gibbs H, Merriman E, et al., 2019, New Guidelines from the Thrombosis and Haemostasis Society of Australia and New Zealand for the Diagnosis and Management of Venous Thromboembolism. Med J Aust, 210(5): 227-235.

Saelim W, Boonmuang P, Suphanklang J, et al., 2020, Clinical Factor Related to International Normalized Ratio Changes in Warfarin Users Who Underwent Heart Valve Replacement at Warfarin Clinic of Phramongkutklao Hospital. Thai Bulletin of Pharmaceutical Science, 15(2): 73-79.

Helin T, Joutsi-Korhonen L, Lassila R, 2019, Clinical Use and Laboratory Testing of Oral Anticoagulation Therapy: Experience from Finland. Annals of Blood, 4: 17.

Barnes GD, Kaatz S, Golgotiu V, et al., 2013, Use of Warfarin for Venous Thromboembolism Prophylaxis Following Knee and Hip Arthroplasty: Results of the Michigan Anticoagulation Quality Improvement Initiative (MAQI2). Journal of Thrombosis and Thrombolysis, 35(1): 10-14.

Dawson NL, Klipa D, O’Brien AK, et al., 2011, Oral Anticoagulation in the Hospital: Analysis of Patients at Risk. Journal of Thrombosis and Thrombolysis, 31(1): 22-26.

Kose E, An T, Kikkawa A, 2018, Assessment of Oral Anticoagulation Control at Pharmacist-Managed Clinics: A Retrospective Cohort Study. Pharmazie, 73(6): 356-360.

Daniels PR, Manning DM, Moriarty JP, et al., 2018, Improving Inpatient Warfarin Therapy Safety Using a Pharmacist-Managed Protocol. BMJ, 7(2): e000290.

Sargin M, Tasdemir MM, Kuplay H, et al., 2019, Retrospective Cohort Study for Evaluating the INR Monitoring Patterns in Patients with Deep Vein Thrombosis in Daily Practice: Analysis of 2010-2013 Database of a Tertiary Care Center. Phlebology, 34(5): 317-323.

Anich KV, Witt DM, Delate T, et al., 2005, A Descriptive Evaluation of Routine Complete Blood Count Monitoring in Patients Receiving Anticoagulation Therapy. J Thromb Thrombolysis, 20(3): 183-188.

Chiquette E, Amato M, Bussey HI, 1998, Comparison of an Anticoagulation Clinic with Usual Medical Care: Atrial Fibrillation and Prophylaxis in Italian Inpatients 229 Anticoagulation Control, Patient Outcomes, and Health Care Costs. Archives of Internal Medicine, 158(15): 1641-1647.