Bibliography

Shortly after his discovery of the toxic substance in spoiled sweet clover (dicoumarol) in 1941, Karl Paul Link stated, \"the clinical use of Dicumarol must be controlled by . . . prothrombin determinations, for altering the coagulability of the blood . . . is a hazardous business. The hasty and the ill-prepared [clinicians] have run into the obvious difficulties.\" (1)

How prescient he was to understand the complexities of managing a narrow therapeutic index drug such as dicoumarol, or its later derivatives, warfarin, acenocoumarol or phenprocoumon. More than 50 years later, we are still struggling with this problem, and learning that the efforts put forth in optimizing therapeutic intensity or defining appropriate indications fall by the wayside if current \"usual\" management results in a combined rate of major hemorrhage and thrombosis of between 10% - 20%.

In many countries, anticoagulation clinics lead the way to improving therapeutic outcomes, but now we have the technology to take the next step forward. With the introduction in 1987 of capillary whole blood prothrombin time monitors (2), there has been a rush to assess the benefits of point-of-care testing, either at the bedside (3), the office or clinic (4) or the home (5-10). But it will be patient self-management that will yield the ultimate in patient empowerment, patient satisfaction, and potentially quality and cost Early studies of patient self- monitoring merely tested the waters by asking patients to measure their INR, but not adjust their own oral anticoagulant dose. Others jumped right in and determined a patient\'s ability to not only monitor their INR, but to manage their anticoagulant dose.

Patient self-management has several barriers - - physician reluctance; payers\' unwillingness to pay; manufacturers\' high prices; and difficulty of implementation. But these are only temporary hurdles. In the next century, patient self-management of oral anticoagulant therapy will become the principal therapeutic model of care, just as it is for diabetics who manage their own insulin therapy. A major impetus in achieving this goal will be the results of prospective randomized studies confirming the safety, efficacy and enhanced clinical outcomes that patient self-management can achieve.