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Journal of General Internal Medicine

, Volume 28, Issue 10, pp 1333–1339 | Cite as

Identifying the Risks of Anticoagulation in Patients with Substance Abuse

  • Lydia M. Efird
  • Donald R. Miller
  • Arlene S. Ash
  • Dan R. Berlowitz
  • Al Ozonoff
  • Shibei Zhao
  • Joel I. Reisman
  • Guneet K. Jasuja
  • Adam J. Rose
Original Research

ABSTRACT

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.

KEY WORDS

anticoagulation alcohol abuse drug abuse 

Notes

Acknowledgements

Contributors

No further contributors.

Funding

This study was supported by a grant from VA Health Services Research and Development (IIR-10-374). Dr. Rose is supported by a career development award from VA Health Services Research and Development (CDA-08-017). The sponsor had no role in the design and conduct of the study; the collection, management, analysis, and interpretation of the data; or the preparation, review, and approval of the manuscript.

Disclaimer

The opinions expressed in this manuscript do not necessarily represent the official views of the Department of Veterans Affairs.

Guarantor

Dr. Rose is the guarantor of the entire manuscript.

Presentations

No prior presentations.

Conflict of Interest

The authors declare that they do not have any conflicts of interest.

Supplementary material

11606_2013_2453_MOESM1_ESM.docx (27 kb)
ESM 1 (DOCX 26 kb)

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Copyright information

© Society of General Internal Medicine 2013

Authors and Affiliations

  • Lydia M. Efird
    • 2
  • Donald R. Miller
    • 1
    • 3
  • Arlene S. Ash
    • 1
    • 2
    • 4
  • Dan R. Berlowitz
    • 1
    • 2
    • 3
  • Al Ozonoff
    • 1
    • 5
  • Shibei Zhao
    • 1
  • Joel I. Reisman
    • 1
  • Guneet K. Jasuja
    • 1
    • 3
  • Adam J. Rose
    • 1
    • 2
  1. 1.Center for Health Quality, Outcomes, and Economic Research, Bedford VA Medical CenterBedfordUSA
  2. 2.Department of Medicine, Section of General Internal MedicineBoston University School of MedicineBostonUSA
  3. 3.Department of Health Policy and ManagementBoston University School of Public HealthBostonUSA
  4. 4.Department of Quantitative Health Sciences, Division of Biostatistics and Health Services ResearchUniversity of Massachusetts School of MedicineWorcesterUSA
  5. 5.Biostatistics Section, Boston Children’s HospitalBostonUSA

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