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After completion of this chapter, the reader should be able to:


  1. Identify common disease states that require anticoagulation.

  2. Understand the value of an anticoagulation therapy service.

  3. Evaluate the risks involved in providing anticoagulation therapy management services.

  4. Evaluate the internal needs of the service including staffing and clerical support, space to assess patients, and laboratory services.

  5. Develop a communication system with local health-care providers for patient referrals and patient report follow-up.

  6. Understand the importance of the development of standard operating procedures for improved efficiency and effectiveness.

  7. Identify potential training opportunities to ensure the delivery of optimized anticoagulant therapy.


Community pharmacies continue to expand their practice by offering innovative patient care services, specifically medication therapy management (MTM) services. The role of anticoagulation services may have a positive outcome in patients, when compared with “usual care” (i.e., personal physician) with potentials for decreases in bleeding and thromboembolism.1 An anticoagulation service in a community pharmacy is a prime example of a MTM service that can be offered. Pharmacists providing anticoagulation services can improve patient outcomes and reduce the risk of adverse events.2,3,4,5 New anticoagulants (i.e., Pradaxa®/Xarelto®) that do not require continuous international normalized ratio (INR) monitoring have recently been introduced but do not preclude the need for pharmacist-provided anticoagulation services. Warfarin is still the treatment of choice for many patients requiring anticoagulation (e.g., prosthetic valve [PV] replacement).6 Managing oral anticoagulation with warfarin requires comprehensive, individualized attention to interactions with a patient's dietary patterns, OTC (over-the-counter) medications, prescription medications, and even lifestyle changes.


Warfarin is a product discovered over 60 years ago by scientists studying why cattle were spontaneously hemorrhaging and dying. The funding for much of this research came from the Wisconsin Alumni Research Foundation thus forming the first part of the name, warfarin, with the second part of the name due to it being a coumarin derivative.7 Clinical application later developed in 1955 when then President Dwight Eisenhower was given warfarin after suffering a myocardial infarction. Due to the narrow therapeutic window of warfarin, additional developments in monitoring were needed. Prothrombin time monitoring was initially developed and in 1982, the INR by the World Health Organization (WHO) became the standard system of anticoagulation control worldwide.8


Multiple disease states necessitate the need for oral anticoagulation to prevent many adverse sequela. While a review of all of the necessary situations in which anticoagulation could be indicated is beyond the scope of this chapter, the most common clinical situations that result in oral anticoagulation management with vitamin K antagonists (e.g., warfarin) are reviewed.


Stroke prevention secondary to atrial fibrillation is one of the most common reasons patients require anticoagulation. Atrial fibrillation is a major risk factor for ischemic stroke. It is estimated that approximately 2.3 million Americans have sustained or paroxysmal atrial fibrillation. Atrial appendage embolism thrombi secondary ...

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