In a primary retail setting, it’s very nerve-racking for someone who likes to play with a lot of patient care as a pharmacist to get a warfarin patient in, and they’re in a hurry and you can’t get your materials through to them. There are all these things impeding on your education to the patient. Now, it’s easier. It’s not as stressful because we have the protocol that we follow. We are very able to get ahold of doctors and nurses and all of the players in the group. We are much more team approached. It’s a lot less stressful. [Long-term care as opposed to retail.] (Alberta).

It’s a very frustrating drug because of the variability in INRs and because patients have to be tested. I have patients who have been on warfarin for 20 years. That’s very tough (Alberta).

I love it. I’m in management. So this is really my clinical component as opposed to my job. We have prescriptive authority in the province so it gives me the capability to utilize that. The educational component; the patient contact; the working with the physicians. All of it, it’s very rewarding (Ontario).

Certainly it is rewarding and in terms of how other professionals view you too, I mean, there is more of a collaborative care process. Again I’m speaking from a community perspective, and in the hospital it tends to be different with pharmacists, but in the community the pharmacist’s role hasn’t gone into that area except for the family health team where they’re directly involved with that team (Ontario).

It’s great. We have over 600 patients. The clinic has been running for five years. I just find it rewarding to be able to communicate with the patients. We have a lot of patients that we may be the only people they see and pick up things and communicate with the doctors (Ontario).

We work under medical directive so we do prescribe warfarin as well. You’re actually putting your hands on the patient which is a little bit different for pharmacists. For pharmacists, we generally don’t do that and that gives you a totally different relationship with that patient and them with you (Ontario).

Working in the hospital you gain a lot of independence. So in our clinics the pharmacists do all the dosing and the physicians are just there if problems arise. In comparison to community pharmacy, I have a lot more opportunity to interact with the patients and really get to know them. And to be able to make decisions about their care. In community, you are kind of just told what to do and you carry it out. I feel like I’m more involved (Ontario).

I did visiting nursing before so I was comfortable with the patients and being a nurse we are comfortable with putting your hands on them. We are used to that. Them managing their warfarin and them being so involved. We also found too that patients coming in we’re also catching other health concerns (Ontario).

Your interactions are well-known. You can adjust those interactions. It’s reversible. It is annoying, but it provides a lot of people with jobs. There are a lot of people tied up in running it. It’s onerous, but it’s there and it’s effective (Alberta).

Some of the merits are in the indications. It certainly does reduce the risk of stroke and heart attack. We also administer warfarin for patients that have poor function of the left ventricle, or a part of it, after heart attack. It could develop clots. There are merits to preventing that. I think a great thing that’s happened is all these anticoagulation clinics that are now in place. They certainly keep right on top of the INR’s (Alberta).

And actually it becomes something that they [patients] become more invested in their healthcare period, not just the anticoagulation. Whatever their issues are, now they know that they can get information (Ontario).

It’s an inexpensive product. It doesn’t put a lot of financial burden on the patient (Alberta).

The advantage is there is a pretty good window. So it will accommodate the patient that forgets the dose and that type of thing. It’s all about the monitoring. Ultimately if you have good monitoring you can manage that patient quite well (Ontario).

With our patients, probably falls is a huge thing — especially with the geriatric population. Worrying about bleeding out. We are dealing with patients at risk of falling (Alberta).

Adverse drug interaction is huge. That’s where they like to challenge us. Every time they get to be on an antibiotic or antidrug that is high codeine we have to closely monitor it (Alberta).

It’s kind of a dirty drug, a lot of drug interactions, a lot of other problems with it; lab monitoring is always an issue, compliance to make sure they come in and to get their INR tested. Those are probably the major points (Alberta).

Some physicians tend to apply their doses too exactly. I don’t think a small quarter of a milligram change in dose is going to make too much of a difference. They do things like splitting the tablets which makes the dose even more inaccurate. There’s more intervention time. There’s more discussing with the doctor. Related to that is unstable INRs. You try to figure out why, but you can’t figure it out. They just fall off the chart. Nothing has changed but for some reason it’s off. So you always question if the INR result is accurate (Alberta).

There are a lot of pharmacists out there who are not familiar enough. That is a real challenge (Alberta).

On the downside, the fact it often takes a couple days to start working and it’s not as quick is also a factor too. Patients need instant relief (Alberta).

The risk has to be lower than the benefits. If someone has one arrhythmia, it’s not appropriate. You can manage that guy on Aspirin. Or if you have someone at a high risk of stroke, or they fall or they’re demented and can’t take their pills. You have to weigh those risks. It’s all related to how much a person will benefit from trying it (Alberta).

I would say compliance. You have to be willing to get tested. Willing to get INRs taken. You have to draw blood on a regular basis. There are clients who don’t want anything to do with getting tested (Alberta).

The cognitive ability to understand those changes. A good family support structure (Alberta).

Yeah for sure there are poor candidates. But then you know it’s also about the ability to communicate with that patient. You can’t do it with everyone. In terms of some people just do not respond well. And that patient is generally not invested in the therapy and that’s the patient where you run into problems. And we’ve had that situation with younger patients for example. Where they are not that compliant because they’re going to go out and party on the weekend. That type of thing (Ontario).

The other patient that is not a particularly good candidate are patients that are really difficult to control. That’s because of other things going on in their medical lives, or their own genetic makeup. Those people are a huge challenge because it’s not about their unwillingness, its more about just that they’re up and down and disease states are taking control and the levels go everywhere. That’s also the type of patient where there are concerns (Ontario).

The challenges of other medical considerations, those are going to be there. The young. The middle aged and the old. Sometimes it’s actually kind of fun to work with physicians to find a solution to the problems. Those adjustments of other meds or changing them to something totally different if there are issues. That kind of adds to the fun working through this clinic (Ontario).

Oncology patients have a difficult time managing their INR as well. Because they’re on and off chemo therapy they have nausea, vomiting — just a lot of other factors interacting. Cancer itself will throw off the anticoagulation cycle. So that’s problematic on all kinds of levels (Ontario).

Cognitive ability. With a number of elderly patients, depending on if they have additional caregivers that can help them or if they’re on their own cognitive ability can do even simply things like remember to take their pills is an issue (Ontario).

… Some of them have unstable lifestyles; we sometimes have patients that are living in and out of shelters. Don’t have money to cover their medications. Sometimes with those patients we have to try and figure out alternative arrangements (Ontario).

They might decide to never go on warfarin at all. Some people are very much against it (Alberta).

If they are hypersensitive to the drug for some reason. Perhaps they have an allergy or they are on other medications that conflict with warfarin. Then we’d have to move them off as well (Alberta).

I use nomograms mixed with your knowledge and experience with that person (Alberta).

We rely on physicians to direct us as to what orders we’re supposed to do and what we’re supposed to look for as well (Alberta).

When patients are in the hospital, an INR is drawn from the lab. We get the results back and either phone it in or show the physician. We get a direct order as to what the dose of Coumadin is. That gets sent to the pharmacy. The pharmacy processes the order and brings it up and we dispense it. It’s fairly regimented. There are always conversations going on between the pharmacy and the physicians (Alberta).

Where I work, some patients come into the lab every day to get their blood work done or get their medication. It’s stabilized where the doctor wants it to be. Then we get a print-out and show the doctor, who decides if they want to change the dose (Alberta).

We do meds for long-term care facilities or retirement homes. They’re controlled dose packaging. We have some of our homes take care of their warfarin protocols on their own. And we have our own warfarin protocols as well, that we get permission from the physician to administer the protocol. We’re adjusting doses when we get the INR readings of either Net Care or the lab… We’re very involved in the adjustment of doses as well. We don’t see our patients as much because most of the ones that are getting really controlled doses have some nursing care as well. We don’t get out to the homes as much. We do have consultant practices who speak with the patients. It’s more the nursing staff and the dietary departments (Alberta).

I’m with the family health team so our clinic is by doctor referral and they have to be patients of the doctors that are in the family health team. So currently we have about 60 doctors in the family health team and 30 more coming on shortly. Their first appointment is they try set up with the pharmacist but sometimes that doesn’t work and they have to come in sooner, so the nurses in the clinic will do the first visit. We do the point of care with the machine and what we do is we give them a calendar and we write the dose in calendar and when they need to come back. So then they just bring that calendar every time they come. Because we get their INR right away and we do their doses. We also go right into their medical chart. Because we have access to all the doctors that are on the family health team and we have access to their charts, so we can go right in and can look up everything (Ontario).

In our practice, patients are referred to the clinic. So it could be referrals from physicians that are discharging them from hospital, or from community physicians. So then on their first appointment they come to the clinic, get a point of care INR test and meet with a physician for 10 to 20 minutes to gather their history. Each visit after that they have their INR testing done, then meet with the pharmacist (Ontario).

They only meet with the physician on the initial appointment. And then if any problems develop that the pharmacists don’t feel like they can deal with. But in most cases the pharmacist feels like they can deal with it. We have point of care testing. We have lab technicians that take a finger prick and put it in the machine and it reads a value within 20 to 30 seconds so. We’re able to dose it right away (Ontario).

We are strictly a pharmacist-run clinic. We have no nursing involvement whatsoever. We basically bring the patient in after we receive the physician’s referral form which gives us a diagnosis. We check with the family physician to see if there are any other pertinent health issues that we should be concerned with. We bring the patient in for the initial hour and a half education component and bring them back in about three days to whatever lab facility they wish to go to. We have arrangements with all lab facilities within the city and then also the surrounding towns that they will fax or phone results if critical. At that point we’ll determine warfarin doses for the next number of days and we do phone follow-up with patients. So an initial one on one and then subsequent to that we do phone follow-up. If there are other issues we’ll bring them back to hospital and basically go through further education or answer questions (Ontario).

By referral because we do work under community pharmacy setting but it’s in a medical building so we do have a number of family doctors that do use our clinic, but a lot of our referrals do come from the cardiologists or people who are being discharged from hospital because either the family physician isn’t available or they don’t have one, whatever it is (Ontario).

One of the real challenges for us is the fact that none of this is funded by any government program so the strips are quite expensive. We use point of care and consequently the patients have to pay to participate in the clinic. So far it’s been as I say, we have very committed patients and it’s quite interesting to see why they do use our clinic. But they do. We do hold them at some occasion as well where it’s appropriate (Ontario).

The only other thing I might mention is because we are in this particular medical clinic we do have access to the INR and it becomes very important for us to have that information because a lot of patients really don’t know what their medical conditions are all about. We find that extremely useful. Plus we enter the results right into the patient’s record for the physician to see as well as whatever we’re doing in terms of dosing (Ontario).

We have a physician who has agreed to be our medical director. So if there is any patient where we need a medical opinion specific to the warfarin or the therapy than we can contact him. As far as nurses, because it’s point of care it’s very simple, and we do have technicians who can assist us with drawing samples where necessary. Other than that it’s strictly pharmacists (Ontario).

Right now, physicians are struggling. There’s no way physicians have time to ever teach. They are juggling the INR. They cut it by way over 10% or they’ll increase it by too high and the INR will take weeks before it settles down again. Ideally, it would be nice if we could really look at who’s the best person to deal with warfarin properly. I would think the pharmacist should rise up to it (Alberta).

Warfarin is being managed by pharmacists, nurses, physicians, and practitioners, and if there’s three or four on the same patient, you’re going to get messes. You’re going to mess up. I think she’s right. It needs to be accountable to one person. Physicians were historically the ones dosing and setting up INRs and now they have too much on their plate. So they head out to the warfarin clinics (Alberta).

We’re using Pharma-file out of Quebec. It’s a support system, so basically for warfarin. We can put the dose right in and calculate how much we’re changing it in percentage. We can also do a printout of the pills for the patient. So if they have two different doses we actually give a printout in colour of what doses they take every day. So that does it right through Pharma-file (Ontario).

We use Pharma-file as well. They do have two in their program — two mg groups. You know, there’s a lot of clinical decision-making that goes into dosing warfarin (Ontario).

We don’t. We just rely on clinical judgment (Ontario).

We don’t have a computer system. We do have a protocol set but we don’t necessarily follow it. There’s sort of a mathematical way you can do it but we don’t often do that, we just use more clinical judgement (Ontario).

We look at the CHADS guidelines, which I hear they are coming out with a new one in January (Ontario).

First visit and every time they come in basically because they don’t get everything at first. And in the calendar we give them it has information in it as well. It’s just the size of a chequebook and has the information all about warfarin and about food interactions and stuff like that (Ontario).

We’ve come up with a very comprehensive guide to taking warfarin including list of foods with the high Vitamin K and number of micrograms of that type of food so it gives you a very clear idea of how much of something they can consume. On top of which we recommend they have at least 100 mg of Vitamin K daily in their diet. And we found a lot of patients wouldn’t touch anything that looked green, so we found it quite helpful. As I said it’s very comprehensive. It gives a patient something to refer to if it’s three in the morning (Ontario).

We do face-to face but we do supply a written material for them as well. We put together a booklet with basically the same type of information. A calendar we prepared so it gives them a place to record their dose and their next INR. It’s too bad that sites do not have the capability to share the information we have put together because it sounds like we have all tried to reinvent the same wheel when a lot of us have put a lot of time and effort into it and anybody that wants to use this information is more than happy to have it (Ontario).

It’s ongoing every time they come into the clinic; we ask them how they’re doing, ask if they have any questions and they often ask questions. Like if their INR is high, why is it going high? We do give them a calendar that does have warfarin information in the front, we tell them to refer to that and not the information sheet they get from their pharmacy because we found that there’s a lot of misinformation in the pharmacy handout sheet (Ontario).

I think the best way to manage warfarin therapy is to do a lot of good teaching with the patient so they are aware of what the drug does. They have to have the commitment to doing the INRs. They have to be at low risk for bleeding so you have to do patient history to figure that out. I have some patients that manage their own INRs and the ability to take home that responsibility. They do great. The lab will give them their INRs with permission from their physician and they just manage their dosing and they just seem to sail along very well. In some ways, I think that works the best. A lot of patients aren’t appropriate for that because their family doctor isn’t there or hasn’t seen their INR. I think a lot of good teaching and awareness of effects (Alberta).

Teaching helps them understand what warfarin is. It’s working against the Vitamin K. It’s all about balancing. What INR means? The reason why? Warfarin takes up to five days before you know what the full effect is. All of these teachings help the patient have comfort (Alberta).

We try to use education as much as possible. We will reinforce the importance of making sure they are compliant not only to their medication taking, but also to their INR draws. We have used everything from one-on-one education, to having somebody else talk to them as far as one of our other staff. We will have the family come in, we will see if we can work with the family to make it easier to a point of, I guess you could call it threatening, basically, that if compliance is going to continue to be an issue and it is nothing more than an issue of non-compliance by the patient themselves, then we tell them that these are the consequences that you are going to face as far as the possibility of increased percentage and we may have to discharge you from our clinic. And refer you back to our family physician. A lot of times that seems to work for the really non-compliant patients, so those are kind of the ways we approach it (Ontario).

Every time you go to give a Coumadin dose, you need someone to co-sign with you. And when you’re running around trying to get everything done it makes it really difficult to find someone (Alberta).

If there was enough staff there would be no issue (Alberta).

We talked to the branch doctor, who has no idea about his patients and they have to go through the chart and look through what they have to order (Alberta).

Our major resource is humans. Staffing is always an issue so trying to find adequate staff. Having the resources to be able to hire those staff members (Ontario).

We have to limit the number of patients that we can actually accept into the clinic. We have run into issues where we have had to hold the number of patients we were able to manage based on vacancies. We had a number of physicians that were ready to go to the media to make sure that adequate funding was put into the clinics that we’d be able to have a bit of a buffer (Ontario).

For us, because we are in the community and we don’t have funding sources, the strips are very expensive and I think this is an issue for certain patients, they just can’t afford the service (Ontario).

It would be nice for us to go into the community. Right now we aren’t able to do that. Because we belong to the family health team unfortunately we can only service the people who are with the family health team. So that’s kind of hard. It’s hard when some of our patients end up going into nursing homes, so they can’t come into our clinic. Those are the patients that it’s really hard to draw blood [from] and it would be nice if we could go in there and do the point of care clinic for them. As well as people that have surgery or can’t make it into the clinic or are sick, unfortunately those patients, if they can’t make it in, we have to get a lab to go in and they draw it and it costs 30 bucks for that. We are free. They don’t pay for our service. The patient has to pay for it if they can’t make it into us and they can’t make it into a regular lab, so that’s what they have to do. To have a community, if we were able to go out, I think we need more staffing and more funding. We’re funded through the government, but that would be something we’d like to be able to do — more outreach (Ontario).

One of our limitations is that our clinic is only open a half day once a week. Only Thursday morning, so that can be somewhat inconvenient for people who are working. So it would be nice if we had funding to have maybe an evening clinic or a late afternoon clinic to accommodate more people. Another limitation we have is that we’re still using old-fashioned cards for each patient. We’re not computerized at all. It’s just written on a card so if that card gets lost or misplaced we’ve completely lost the records; there’s no computerized records. We have the hospital files of the patient but none of their INRs are linked to that and none of our information is linked to that. So if they’re seeing other physicians in the hospital, none of their INR results will be recorded in the computer system (Ontario).

Where I practise now, yes, but not when I was practising in retail. It depends on who your employer is and what your ratio is to free up your time from this dispensing… That’s the biggest downfall to retail. If you’re in a fill-and-bill type environment, you’re slinging those pills out and it’s like “Go, go, go!” A lot of pharmacists just don’t have the time. Even if they had a simple procedure where the INR would pop up magically, and they had a nomogram they could follow, they’d still need the time to sit and think about it. It’s a real problem. Retail is struggling with regulated technicians. If retail pharmacy jumps on board with it, it certainly would free up time for pharmacists to have more responsibilities (Alberta).

Technicians are on call on the weekends and have designated hours where they get called in on nights. A majority of our blood work is drawn on Mondays and Fridays. Well, if you get an abnormal INR result back on Fridays, a doctor will have to come in and have to reorder on Saturday. Normally, they wouldn’t come in unless they’re called in (Alberta).

We have to make it viable. We can’t operate at a loss. The patients we have certainly are willing to pay that. It’s unfortunate. One woman we saw this afternoon had to be a home visit because she had a leg amputation. So that type of patient, they’re very concerned about their warfarin levels and they’re willing to pay, but it’s not easy for them. So there should be some mechanism to make the process a little easier. The argument could be made, is it cheaper to pay for that strip versus having her admitted into an ER facility because of a bleed or a stroke (Ontario).

They haven’t had any events (Alberta).

They’re usually the kind of person that is compliant with their health care, like diet and taking their medications. One that has stabilized for a few months, only has to go in for blood work once a month, and tries to stay on a fairly regular diet. They are patients who know their dose and are cautious. They are aware of what to look for and when to go in for blood work (Ontario).

When they start up with the anticoagulation clinic there is a letter of consent that they sign as part of documentation. In that letter of consent they agree to attend their appointment and all of the compliance issues. That’s part of their consent letter and it’s stated there as well that if it’s not working out for them that they’re not being compliant they’d be referred back. We have only had one case like that (Ontario).

Patients with dementia (Alberta).

I deal with patients with chronic heart problems and a lot of them are quite elderly. I had a man who seemed very lucid and together and always said he was doing this and that. He’d come in and I would check on him and he didn’t have his INRs done and he went into a complete crisis with dementia and had a really high INR result and nobody could get ahold of him. That’s very scary (Alberta).

Our hospital is quite close to a reserve that doesn’t always have transportation to get to the hospital. Therefore if they can’t get to the hospital they can’t get their INR or their medication (Alberta).

Someone who still drinks alcohol and goes on binges is also a huge risk (Alberta).

It’s not very expensive, but some people still can’t afford it (Alberta).

We try to determine why they’re having difficulties. We provide education talk about the consequences and identify why there is a problem. Sometimes it could be they can’t afford the medications or they just cannot remember to take it. So then we’ll work with them. We also have free supply available for some patients that are non-compliant. There are still some that are a problem. Some people are just not motivated to take their medication. Our clinic assistant will call people who are late for their testing and encourage them to come back to make sure they realize they are late and encourage them to come back to make sure there are no issues (Ontario).

We do the same thing. We call them. First we make sure they’re not in hospital — we check their chart. We call them about a week or so after if they miss their visit. We call them twice and then we send the message to the family doctor and then the doctor will look at that. We do have some patients that will come whenever they want. It could be three months between visits and they come in and then they’re therapeutic so they don’t see why they need to change, so we educate them and let them know (Ontario).

We have some patients that just seem to forget a dose. So we do fill dosettes as well. We have them come in weekly if they need to, to just keep a closer eye on them to make sure they’re taking the right dose. We really try and keep our patients just to one strength of warfarin if we can because we don’t want them to get mixed up with the different strengths (Ontario).

We do a consistent dose as well if we can and we also don’t like it when we have to split the pills. We do try to work with the pills the patients have but unfortunately it doesn’t work all the time. And you have to try to work around it but for some patients we try to get the families involved if there’s a problem and the patients themselves, because of cognitive abilities or what, can’t manage it (Ontario).

My setting is geriatrics. It really depends on the client’s quality of life and the family. Do we want to treat Mom as aggressively as we did or do we let her go naturally? After discussions of the risks with the physician, we may keep it going slower, lower, and lower, and then just stop (Alberta).

You try until they tell you not to. If they still want to try we’re also being paid to be there. Even if they keep forgetting to take it, if they keep wanting to try, it’s our job to be there. Unless it’s dangerous for the patient (Alberta).

For us it would be on a case-by-case basis. We have carried patients for a number of months based on the best interest for that patient, some of them based on their lifestyle, their inability to get to labs. We have a number of oil workers out in the boonies and they’re not always able to get in the exact time their therapy should be and we‘ve carried them for a while. Others are very young and their lifestyle, they think they’re invincible. We will work with them as long as we think we can. I guess when you get to a point of absolute frustration that’s when we say it’s enough. We also have them sign a patient responsibility form and we use that as a basis to discharge them from our clinic (Ontario).

I guess it depends on how erratic they really are. There are patients that are difficult to control but they’ll be in range for two or three visits and then go out of range. There are usually good reasons for why that’s happening so you try to work with it and tweak it as you go along, so the answer to that is that you just need to see them more frequently (Ontario).

We do a sort of case by case. Right now we have a patient who’s 99 on warfarin, she’s only a two score and one of them is because her age. We kind of look at that because, for some reason, we don’t know what’s going on but we can’t seem to get her INR down. In the past week, she’s had 0.5 mg and her INR was 3.1. We’ve slowly been holding doses and she’s not coming down. Finally we decided to speak with the family physician and they put her on a low dose Aspirin. So in situations like that we look at where their score is and their compliance and their risk of bleeding and in the best interest of the patient we look at other options. For her, she’s just on the Aspirin until they can figure out what is going on. And we explain to her the risks of that. As well as patients who drink quite a bit. We look at their risk of falling and stuff like that. We’ve had patients who have fallen and bled and we look at their risk and they’re just not a good candidate for warfarin in that situation (Ontario).

We mainly go on a case-by-case basis as well. We have had a couple of cases where we have given the patient a low dose of Vitamin K on a daily basis to try and stabilize their INR. It hasn’t been all that successful. We’ve also tried — especially for younger patients — for them to have their own machine at home to check it themselves. It depends on their financial situation. It works for some patients and not for others. Some can’t afford it. So sometimes that helps, especially for younger patients. They don’t have to come into the clinic as often. They check their INR and call it in and they know how to dose it. They might only come in once every three months (Ontario).

If used properly, the lack of lab requirements, the point of testing or having to go in for blood draws, especially if they’re in rural sites and have to travel into labs (Ontario).

It’s a little too much hype, truthfully. It’s probably a great product. People are excited about not having to get INRs. They don’t want to deal with all these interactions. You have to slow down just a little bit. This drug was approved amazingly fast through every regulatory body. I think faster than a lot of people would say is rational. It’s a major thing. It seems very strange to rush through the process for a drug that is potentially one of the more dangerous on the market. It’s not really stable. Why do the US and Canada have different guidelines? It’s not as clear as it should be. You can’t modify the pill in any way. There are a few things about how exciting it is, but I think everyone needs to chill a little bit (Alberta).

One other thing that we’ve found is that it’s twice a day. Some of our patients find it hard enough to remember once a day (Ontario).

Also they want to know what their INR is. There is no test for that. They don’t monitor that like that. So they just say how do I know where I am? And I think that’s the advantage of going to a point of care clinic you’re so involved in their health and now they don’t have that (Ontario).

I think one of the minuses is that no one is checking up on them, so if they’re taking dabigatran twice a day you kind of question what their compliance will be (Ontario).

Another concern that we’ve heard is that I guess they’re in a foil package so the pill itself can’t be in a blister pack. So that’s one concern with patients (Ontario)

Also, the issue of pretty much one dose for people of all weights and all sizes. You really don’t know if it’s going to work the same for someone whose 150 kg vs. 40 kg. A lot of variability there and we really don’t know (Alberta).

They’re saying 150 mg is superior to warfarin, yet the 110 people over the age of 70 so that is comparable to warfarin. So you look at those people and think, what’s the point of changing everything when you’re going to something they say isn’t necessarily superior to warfarin? (Ontario).

I think one other issue is that there are patients who are well controlled for whom there doesn’t seem to be any reason. There’s also the patient that is in range so rather than raising the warfarin dose and increasing bleeding risks, physicians would then consider a product like dabigatran. There are patients who will refuse to take warfarin and there are physicians who are reluctant to prescribe warfarin. So I am hoping that there will be a few more patients who should be anticoagulated and are not because there are a number of different issues. Because some of these are reluctant to take that type of agent, perhaps some of the newer agents will capture some of that population (Ontario).

I’m recommending for someone to go on it. The person was already on warfarin and stroke within the therapeutic range at 2.6. He was being put on. He was on top of it. He’s quite well. Everything is going good for him. He’s quite young — in his seventies. In his case, that was what we recommended (Alberta).

I think that certainly you have to look for the hemorrhagic risk and see which way to go with that (Ontario)

I guess it would be dependent on the control of that patient. Each patient is going to be slightly different, if they were consistent within the therapeutic range then I would consider. If we were having problems with the patients and they were outside the therapeutic range then I would have to look specifically at that patient then discuss with the physician first (Ontario).

I would keep them on warfarin. A lot of times it is easier to control a bleed than it is a clot (Ontario).

And you can reverse the warfarin quickly if you need to (Ontario).

You’re able to manoeuvre that way with warfarin and less with dabigatran. Dabigatran only has the one dose. If you do have a bleed there’s nothing you can really do. With the warfarin the Vitamin K will help out. Dabigatran you’re shooting blind you really don’t know what you’re doing. At least with warfarin you have the INR that you can base your decisions on (Ontario).

We’ve done with some people, say we have a young girl who has factor 5 so she has clotting problems, so she is on warfarin but her menstrual cycles are very heavy so we’ve lowered her dose a little. Lower their dose and we’ve done that with other patients who are on a higher risk of bleeding, we try and keep them on lower therapeutic. So we try and work with that (Ontario).

We attended the conference in Hamilton and in Boston. As well as new information that comes out it’s really helpful the pharmacists are usually the first to get the information and pass it along. We have INR meetings every two months and everything new we research and discuss it (Ontario).

I like the Internet: Clotconnect and Anticoagulation forums. Because of all the new agents there’s a lot with Medscape and so on where they’re doing various reviews. A lot would come from that source (Ontario).

Conferences would be my primary [source] but unfortunately haven’t been to many in a long time. So the Internet would probably be my most utilized source of information (Ontario).

Also, specialists that I know, I would run things by with them (Ontario).

A lot of clinical trials. We have a pretty good relationship with a lot of the drug reps from different companies so they will let us know about their new products and any trials that are going on (Ontario).

We have a number of patients who have gotten monitors for themselves because they travel or are away for six months or whatever (Ontario).

We have some physicians who have been quite worried about it because they’re afraid they’re going to overtest. We have some patients who come in monthly to see us but they’ve tested themselves twice a week and adjust their warfarin accordingly. We don’t want them to test it that frequently and they end up changing their dose. We’d rather them just do it on a weekly basis and just call us and let us know. But even if they’re range is two to three and they’re 3.1, sometimes they’ll change their dose. And it could be just where they are that day. We’d rather just see the whole picture. So you have some people that you just worry that they’re going to change things and worry so much about it (Ontario).

Cost impact is probably going to be a negative impact to them because they don’t pay for their lab services in our province anyhow. The only cost they have for us is the actual cost of the drug. Warfarin being a lot cheaper than dabigatran is (Alberta).

No reversal agents is probably one of my major concerns (Ontario).