{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,27]],"date-time":"2026-07-27T02:00:47Z","timestamp":1785117647169,"version":"3.55.0"},"reference-count":41,"publisher":"MDPI AG","issue":"8","license":[{"start":{"date-parts":[[2026,7,25]],"date-time":"2026-07-25T00:00:00Z","timestamp":1784937600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Clin. Pract.","Clinics and Practice"],"abstract":"<jats:p>Background: Warfarin remains widely used in specific clinical situations. Its management is complicated by multiple factors that affect anticoagulant response, particularly during the early period after hospital discharge. This study examined the prevalence, patterns, and factors associated with nontherapeutic international normalized ratio (INR) among patients discharged on warfarin from a tertiary-care hospital. Methods: Electronic health records of adult patients discharged home with warfarin who had at least one INR measurement within 90 days (N = 1222) were retrospectively analyzed. Nontherapeutic INR was defined as INR outside the therapeutic range: 2.5\u20133.5 for mitral valve replacement and 2.0\u20133.0 otherwise. All available INR measurements were included. Major warfarin potential drug\u2013drug interactions (pDDIs) were defined as DDIs with major severity according to the Micromedex\u00ae database. Factors associated with nontherapeutic INR were examined using repeated-measures generalized estimating equations (GEEs), with generalized linear mixed models (GLMMs) as confirmatory analyses. Results: Of 3704 INR measurements within 90 days after discharge, 49.4% were subtherapeutic, while 30.5% were therapeutic and 20.1% were supratherapeutic. The proportion of therapeutic INR values did not show a substantial improvement over time. In GEEs, discharge from surgical service (adjusted odds ratio (aOR) 1.24, 95%CI: 1.05\u20131.48, p = 0.014) and presence of major warfarin pDDIs at discharge (aOR 1.36, 95%CI: 1.11\u20131.67, p = 0.003) were associated with nontherapeutic INR. GLMM analyses produced consistent results with the GEE model. Conclusions: Suboptimal INR control was prevalent within 90 days post-discharge. Discharge from surgical services and presence of major warfarin pDDIs at discharge were associated with nontherapeutic INRs. Major warfarin pDDIs may serve as markers of medication complexity at discharge and may help identify patients requiring closer anticoagulation monitoring.<\/jats:p>","DOI":"10.3390\/clinpract16080136","type":"journal-article","created":{"date-parts":[[2026,7,27]],"date-time":"2026-07-27T01:26:23Z","timestamp":1785115583000},"page":"136","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Nontherapeutic INR After Hospital Discharge: A Repeated-Measures Analysis of Warfarin-Treated Patients and Potential Drug\u2013Drug Interactions"],"prefix":"10.3390","volume":"16","author":[{"given":"Kanthida","family":"Methaset","sequence":"first","affiliation":[{"name":"Division of Pharmacy Services, Thammasat University Hospital, Pathum Thani 12120, Thailand"},{"name":"Graduate Program in Drug Utilization and Health Outcomes Research, Faculty of Pharmacy, Thammasat University, Pathum Thani 12120, Thailand"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8140-2460","authenticated-orcid":false,"given":"Pattamawan","family":"Kosuma","sequence":"additional","affiliation":[{"name":"Faculty of Pharmacy, Thammasat University, Pathum Thani 12120, Thailand"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5776-1439","authenticated-orcid":false,"given":"Arom","family":"Jedsadayanmata","sequence":"additional","affiliation":[{"name":"Faculty of Pharmacy, Thammasat University, Pathum Thani 12120, Thailand"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,7,25]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"e1","DOI":"10.1161\/CIR.0000000000001193","article-title":"2023 ACC\/AHA\/ACCP\/HRS Guideline for the diagnosis and management of atrial fibrillation: A report of the American College of Cardiology\/American Heart Association Joint Committee on clinical practice guidelines","volume":"149","author":"Joglar","year":"2024","journal-title":"Circulation"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"1901647","DOI":"10.1183\/13993003.01647-2019","article-title":"2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS): The Task Force for the diagnosis and management of acute pulmonary embolism of the European Society of Cardiology (ESC)","volume":"54","author":"Konstantinides","year":"2019","journal-title":"Eur. Respir. J."},{"key":"ref_3","doi-asserted-by":"crossref","unstructured":"Li, Y., Wang, X., Ma, A., Chen, P., and Li, H. (2025). Factors influencing the cost-effectiveness of novel oral anticoagulants compared to vitamin K antagonists in patients with atrial fibrillation: A systematic review. Front. Pharmacol., 16.","DOI":"10.3389\/fphar.2025.1441754"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"53","DOI":"10.1016\/j.vhri.2023.04.005","article-title":"The budget impact analysis of adopting direct oral anticoagulants for stroke prevention in nonvalvular atrial fibrillation patients in Malawi","volume":"37","author":"Chikumbanje","year":"2023","journal-title":"Value Health Reg. Issues"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"135","DOI":"10.2147\/PPA.S152584","article-title":"A survey of reasons for continuing warfarin therapy in the era of direct oral anticoagulants in Japanese patients with atrial fibrillation: The SELECT study","volume":"12","author":"Ikeda","year":"2018","journal-title":"Patient Prefer. Adherence"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"e20190025","DOI":"10.1590\/1678-4685-gmb-2019-0025","article-title":"Identification of environmental and genetic factors that influence warfarin time in therapeutic range","volume":"43","author":"Botton","year":"2020","journal-title":"Genet. Mol. Biol."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"247","DOI":"10.1016\/S0083-6729(07)00012-X","article-title":"Warfarin therapy: Influence of pharmacogenetic and environmental factors on the anticoagulant response to warfarin","volume":"78","author":"Siguret","year":"2008","journal-title":"Vitam. Horm."},{"key":"ref_8","doi-asserted-by":"crossref","unstructured":"D\u00e1vila-Fajardo, C.L., D\u00edaz-Villamar\u00edn, X., Ant\u00fanez-Rodr\u00edguez, A., Fern\u00e1ndez-G\u00f3mez, A.E., Garc\u00eda-Navas, P., Mart\u00ednez-Gonz\u00e1lez, L.J., D\u00e1vila-Fajardo, J.A., and Barrera, J.C. (2019). Pharmacogenetics in the treatment of cardiovascular diseases and its current progress regarding implementation in the clinical routine. Genes, 10.","DOI":"10.3390\/genes10040261"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"250","DOI":"10.1016\/j.thromres.2015.06.007","article-title":"Determinants of oral anticoagulation control in new warfarin patients: Analysis using data from Clinical Practice Research Datalink","volume":"136","author":"Macedo","year":"2015","journal-title":"Thromb. Res."},{"key":"ref_10","doi-asserted-by":"crossref","unstructured":"Camelo-Castillo, A., Rivera-Caravaca, J.M., Orenes-Pi\u00f1ero, E., Ram\u00edrez-Mac\u00edas, I., Rold\u00e1n, V., Lip, G.Y.H., and Mar\u00edn, F. (2021). Gut microbiota and the quality of oral anticoagulation in vitamin K antagonists users: A review of potential implications. J. Clin. Med., 10.","DOI":"10.3390\/jcm10040715"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"160S","DOI":"10.1378\/chest.08-0670","article-title":"Pharmacology and management of the vitamin K antagonists: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition)","volume":"133","author":"Ansell","year":"2008","journal-title":"Chest"},{"key":"ref_12","first-page":"e007956","article-title":"Drug interactions affecting oral anticoagulant use","volume":"15","author":"Mar","year":"2022","journal-title":"Circ. Arrhythm. Electrophysiol."},{"key":"ref_13","doi-asserted-by":"crossref","unstructured":"Zerah, L., Henrard, S., Wilting, I., O\u2019Mahony, D., Rodondi, N., Dalleur, O., Dalton, K., Knol, W., Haschke, M., and Spinewine, A. (2021). Prevalence of drug-drug interactions in older people before and after hospital admission: Analysis from the OPERAM trial. BMC Geriatr., 21.","DOI":"10.1186\/s12877-021-02532-z"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"2364825","DOI":"10.1080\/07853890.2024.2364825","article-title":"Time-in-therapeutic-range defined warfarin and direct oral anticoagulants in atrial fibrillation: A nationwide cohort study","volume":"56","author":"Lehto","year":"2024","journal-title":"Ann. Med."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"472","DOI":"10.1136\/hrt.2004.042465","article-title":"Evaluation of the pattern of treatment, level of anticoagulation control, and outcome of treatment with warfarin in patients with non-valvar atrial fibrillation: A record linkage study in a large British population","volume":"91","author":"Jones","year":"2005","journal-title":"Heart"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"420","DOI":"10.1016\/j.amjcard.2013.03.051","article-title":"Hospitalization for hemorrhage among warfarin recipients prescribed amiodarone","volume":"112","author":"Lam","year":"2013","journal-title":"Am. J. Cardiol."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"20","DOI":"10.1186\/1477-9560-12-20","article-title":"Drug-drug interactions and risk of bleeding among inpatients on warfarin therapy: A prospective observational study","volume":"12","author":"Teklay","year":"2014","journal-title":"Thromb. J."},{"key":"ref_18","first-page":"363","article-title":"Quality of oral anticoagulation in atrial fibrillation patients at a tertiary hospital in Brazil","volume":"119","author":"Malagutte","year":"2022","journal-title":"Arq. Bras. Cardiol."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"235","DOI":"10.1503\/cmaj.080171","article-title":"Anticoagulation intensity and outcomes among patients prescribed oral anticoagulant therapy: A systematic review and meta-analysis","volume":"179","author":"Oake","year":"2008","journal-title":"CMAJ"},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"e024402","DOI":"10.1161\/JAHA.121.024402","article-title":"Association between inappropriately dosed anticoagulation therapy with stroke severity and outcomes in patients with atrial fibrillation","volume":"11","author":"Vinding","year":"2022","journal-title":"J. Am. Heart Assoc."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"1311","DOI":"10.1592\/phco.24.14.1311.43144","article-title":"Frequency and causes of overanticoagulation and underanticoagulation in patients treated with warfarin","volume":"24","author":"Wittkowsky","year":"2004","journal-title":"Pharmacotherapy"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"1996","DOI":"10.1345\/aph.1E381","article-title":"Search for predictors of nontherapeutic INR results with warfarin therapy","volume":"39","author":"Csako","year":"2005","journal-title":"Ann. Pharmacother."},{"key":"ref_23","doi-asserted-by":"crossref","unstructured":"Methaset, K., and Jedsadayanmata, A. (2026). Burden and determinants of drug\u2013drug interactions at hospital discharge: Warfarin as a model for high-risk medication safety. Clin. Pract., 16.","DOI":"10.3390\/clinpract16010008"},{"key":"ref_24","unstructured":"World Health Organization (2019). Medication Safety in Polypharmacy, World Health Organization."},{"key":"ref_25","doi-asserted-by":"crossref","unstructured":"Masnoon, N., Shakib, S., Kalisch-Ellett, L., and Caughey, G.E. (2017). What is polypharmacy? A systematic review of definitions. BMC Geriatr., 17.","DOI":"10.1186\/s12877-017-0621-2"},{"key":"ref_26","first-page":"477","article-title":"Suboptimal anticoagulant management in patients after hospital initiation of warfarin","volume":"33","author":"Jackson","year":"2004","journal-title":"Aust. Fam. Physician"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"588","DOI":"10.1177\/001857870504000707","article-title":"Evaluation of the first international normalized ratio after acute care discharge to the primary care environment","volume":"40","author":"Spray","year":"2005","journal-title":"Hosp. Pharm."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"705","DOI":"10.1016\/j.thromres.2006.05.017","article-title":"The effect of hospitalization on oral anticoagulation control: A population-based study","volume":"119","author":"Austin","year":"2007","journal-title":"Thromb. Res."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"727","DOI":"10.1007\/s11606-006-0064-5","article-title":"Anticoagulation control in the peri-hospitalization period","volume":"22","author":"Forster","year":"2007","journal-title":"J. Gen. Intern. Med."},{"key":"ref_30","doi-asserted-by":"crossref","unstructured":"Asiimwe, I.G., and Pirmohamed, M. (2022). Ethnic diversity and warfarin pharmacogenomics. Front. Pharmacol., 13.","DOI":"10.3389\/fphar.2022.866058"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"309","DOI":"10.1016\/j.jacc.2007.01.098","article-title":"Racial\/ethnic differences in the risk of intracranial hemorrhage among patients with atrial fibrillation","volume":"50","author":"Shen","year":"2007","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"1008","DOI":"10.1345\/aph.1E566","article-title":"The influence of ethnicity on warfarin dosage requirement","volume":"39","author":"Dang","year":"2005","journal-title":"Ann. Pharmacother."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"713","DOI":"10.2217\/14622416.8.7.713","article-title":"Ethnic differences in the VKORC1 gene polymorphism and an association with warfarin dosage requirements in cardiovascular surgery patients","volume":"8","author":"Nakai","year":"2007","journal-title":"Pharmacogenomics"},{"key":"ref_34","doi-asserted-by":"crossref","unstructured":"Kamthornthanakarn, I., and Krittayaphong, R. (2019). Optimal INR level for warfarin therapy after mechanical mitral valve replacement. BMC Cardiovasc. Disord., 19.","DOI":"10.1186\/s12872-019-1078-3"},{"key":"ref_35","doi-asserted-by":"crossref","unstructured":"Ujjin, A., Wongcharoen, W., Suwanagool, A., and Chai-Adisaksopha, C. (2024). Optimal strategies to select warfarin dose for Thai patients with atrial fibrillation. J. Clin. Med., 13.","DOI":"10.3390\/jcm13092675"},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"4051","DOI":"10.1111\/bcp.14833","article-title":"Drug-drug interactions with warfarin: A systematic review and meta-analysis","volume":"87","author":"Wang","year":"2021","journal-title":"Br. J. Clin. Pharmacol."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"54","DOI":"10.1097\/JCN.0b013e31823776e6","article-title":"Transitions of care in patients receiving oral anticoagulants: General principles, procedures, and impact of new oral anticoagulants","volume":"28","author":"Johnson","year":"2013","journal-title":"J. Cardiovasc. Nurs."},{"key":"ref_38","doi-asserted-by":"crossref","unstructured":"Solh Dost, L., Gastaldi, G., and Schneider, M.P. (2024). Patient medication management, understanding and adherence during the transition from hospital to outpatient care\u2014A qualitative longitudinal study in polymorbid patients with type 2 diabetes. BMC Health Serv. Res., 24.","DOI":"10.1186\/s12913-024-10784-9"},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"1076029619872554","DOI":"10.1177\/1076029619872554","article-title":"Preemptive dose adjustment effect on the quality of anticoagulation management in warfarin patients with drug interactions: A retrospective cohort study","volume":"25","author":"Fahmi","year":"2019","journal-title":"Clin. Appl. Thromb. Hemost."},{"key":"ref_40","first-page":"630","article-title":"Defining minimum necessary anticoagulation-related communication at discharge: Consensus of the Care Transitions Task Force of the New York State Anticoagulation Coalition","volume":"44","author":"Triller","year":"2018","journal-title":"Jt. Comm. J. Qual. Patient Saf."},{"key":"ref_41","doi-asserted-by":"crossref","unstructured":"Karaoui, L.R., Ramia, E., Mansour, H., Haddad, N., and Chamoun, N. (2021). Impact of pharmacist-conducted anticoagulation patient education and telephone follow-up on transitions of care: A randomized controlled trial. BMC Health Serv. Res., 21.","DOI":"10.1186\/s12913-021-06156-2"}],"container-title":["Clinics and Practice"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2039-7283\/16\/8\/136\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,7,27]],"date-time":"2026-07-27T01:51:34Z","timestamp":1785117094000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2039-7283\/16\/8\/136"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,7,25]]},"references-count":41,"journal-issue":{"issue":"8","published-online":{"date-parts":[[2026,8]]}},"alternative-id":["clinpract16080136"],"URL":"https:\/\/doi.org\/10.3390\/clinpract16080136","relation":{},"ISSN":["2039-7283"],"issn-type":[{"value":"2039-7283","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,7,25]]}}}