Impact of Pharmaceutical Care on Self-Administration of Outpatient Low-Molecular-Weight Heparin Therapy


Outpatient subcutaneous (s.c.) therapies are becoming more and more common in the treatment of different diseases. The effectiveness of community-pharmacy-based interventions in preventing problems that arise during s.c. self-injections of low-molecular-weight heparins (LMWH) is unknown. Our objective was to provide a standard operating procedure (SOP) for community pharmacists and to compare pharmaceutical vs. standard care in both clinical and daily life settings. We hypothesized that: pharmaceutical care results in improved adherence, safety, and satisfaction, and in fewer complications; the interventions used are feasible in daily life; and the results achieved in clinical and daily life settings are comparable. In the clinical setting (randomized controlled trial), patients were recruited sequentially in hospital wards; in the daily life setting (quasi-experimental design with a comparison group), recruitment took place in community pharmacies by pharmacists and trained master students during their internship. Interventions were offered according to patient needs. Data were collected by means of a monitored self-injection at home and structured questionnaire-based telephone interviews at the beginning and the end of the LMWH treatment. The main outcome measures were: scores to assess patient’s skills; syringe count to assess adherence; and frequency, effectiveness, and patient’s assessment of received interventions. The results show a median age of the 139 patients of 54 years. Interventions resulted in improved application quality (p < 0.01) and knowledge (p = 0.03). Oral instructions were pivotal for improving patients’ application quality. We found no significant score differences between the intervention groups in the clinical and daily life settings. Patients’ baseline skills were high, with the lowest score being 0.86 (score range ?2.00 to +2.00). Adherence rate was high (95.8%). In conclusion, our SOP for pharmacist interventions was of good quality, adequate, appreciated, and feasible in daily life. Patients are capable of managing s.c. injection therapies if adequate assistance is provided.

Share and Cite:

Mengiardi, S. , Tsakiris, D. , Molnar, V. , Kohlhaas-Styk, U. , Mittag, M. , Kraehenbuehl, S. and Hersberger, K. (2014) Impact of Pharmaceutical Care on Self-Administration of Outpatient Low-Molecular-Weight Heparin Therapy. Pharmacology & Pharmacy, 5, 372-385. doi: 10.4236/pp.2014.54045.

Conflicts of Interest

The authors declare no conflicts of interest.


[1] Guyatt, G.H., Akl, E.A., Crowther, M., Gutterman, D.D. and Schuunemann, H.J. (2012) Executive Summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th Ed.: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest, 141, 7S-47S.
[2] Wiesner, C. (2001) Arzneimittelsicherheit in der Perihospitalphase—Eine patientenbezogene Analyse des Pharmakotherapieprozesses. Ph.D. Thesis, University of Basel, Basel.
[3] Hepler, C.D. and Strand, L.M. (1990) Opportunities and Responsibilities in Pharmaceutical Care. American Journal of Hospital Pharmacy, 47, 533-543.
[4] Frokjaer, B., Sondergaard, B. and Herborg, H. (2004) Evidence Report 3—Follow-Up on Outcomes of Drug Therapy (Pharmaceutical Care). Pharmakon, 1-16.
[5] Blenkinsopp, A. and Hassey, A. (2005) Effectiveness and Acceptability of Community Pharmacy-Based Interventions in Type 2 Diabetes: A Critical Review of Intervention Design, Pharmacist and Patient Perspectives. International Journal of Pharmacy Practice, 13, 231-240.
[6] Roughead, E.E., Semple, S.J. and Vitry, A.I. (2005) Pharmaceutical Care Services: A Systematic Review of Published Studies, 1990 to 2003, Examining Effectiveness in Improving Patient Outcomes. International Journal of Pharmacy Practice, 13, 53-70.
[7] Machado, M., Bajcar, J., Guzzo, G.C. and Einarson, T.R. (2007) Sensitivity of Patient Outcomes to Pharmacist Interventions. Part II: Systematic Review and Meta-Analysis in Hypertension Management. The Annals of Pharmacotherapy, 41, 1770-1781.
[8] Machado, M., Bajcar, J., Guzzo, G.C. and Einarson, T.R. (2007) Sensitivity of Patient Outcomes to Pharmacist Interventions. Part I: Systematic Review and Meta-Analysis in Diabetes Management. The Annals of Pharmacotherapy, 41, 1569-1582.
[9] Machado, M., Nassor, N., Bajcar, J.M., Guzzo, G.C. and Einarson, T.R. (2008) Sensitivity of Patient Outcomes to Pharmacist Interventions. Part III: Systematic Review and Meta-Analysis in Hyperlipidemia Management. The Annals of Pharmacotherapy, 42, 1195-1207.
[10] Wubben, D.P. and Vivian, E.M. (2008) Effects of Pharmacist Outpatient Interventions on Adults with Diabetes Mellitus: A Systematic Review. Pharmacotherapy, 28, 421-436.
[11] Miller, N.H., Hill, M., Kottke, T. and Ockene, I.S. (1997) The Multilevel Compliance Challenge: Recommendations for a Call to Action. A Statement for Healthcare Professionals. Circulation, 95, 1085-1090.
[12] Haynes, R.B., Ackloo, E., Sahota, N., McDonald, H.P. and Yao, X. (2008) Interventions for Enhancing Medication Adherence. Cochrane Database of Systematic Reviews, 2, CD000011.
[13] Mengiardi, S., Goepfert, B., Tsakiris, D.A. and Hersberger, K.E. (2009) Pitfalls in Patient Self-Management of Subcutaneous Drug Application: Removal of Rubber Protection Caps from Ready-to-Use Syringes. European Journal of Clinical Pharmacology, 65, 1061-1062.
[14] Mengiardi, S., Tsakiris, D.A., Lampert, M.L. and Hersberger, K.E. (2011) Drug Use Problems with Self-Injected Low-Molecular-Weight Heparins in Primary Care. European Journal of Clinical Pharmacology, 67, 109-120.
[15] Karch, A.M. (2004) A Needling Problem. American Journal of Nursing, 104, 81-83.
[16] Colwell, C.W., Pullido, P., Hardwick, M.E. and Morris, B.A. (2005) Patient Compliance with Outpatient Prophylaxis: An Observational Study. Orthopedics, 28, 143-147.
[17] Spahn, G. (2002) Compliance with Self-Administration of Heparin Injections in Outpatients. European Journal of Trauma and Emergency Surgery, 28, 104-109.
[18] Watts, A.C., Howie, C.R. and Simpson, A.H. (2006) Assessment of a Self-Administration Protocol for Extended Subcutaneous Thromboprophylaxis in Lower Limb Arthroplasty. The Journal of Bone and Joint Surgery (British Volume), 88, 107-110.
[19] Le Gall, C., Jacques, E., Medjebeur, C., Darques, L., Briand, F., Haddad, J., et al. (2006) Low Molecular Weight Heparin Self-Injection Training: Assessment of Feasibility, Tolerance and Economic Analysis in Emergency Departments. European Journal of Emergency Medicine, 13, 264-269.
[20] Piazza, G., Nguyen, T.N., Morrison, R., Cios, D., Hohlfelder, B., Fanikos, J., et al. (2012) Patient Education Program for Venous Thromboembolism Prevention in Hospitalized Patients. The American Journal of Medicine, 125, 258-264.
[21] Urbaniak, G.C. and Plous, S. (2007) Research Randomizer (Version 3.0). Computer Software.
[22] Zaybak, A. and Khorshid, L. (2008) A Study on the Effect of the Duration of Subcutaneous Heparin Injection on Bruising and Pain. Journal of Clinical Nursing, 17, 378-385.
[23] Chan, H. (2001) Effects of Injection Duration on Site-Pain Intensity and Bruising Associated with Subcutaneous Heparin. Journal of Advanced Nursing, 35, 882-892.
[24] Balci Akpinar, R. and Celebioglu, A. (2008) Effect of Injection Duration on Bruising Associated with Subcutaneous Heparin: A Quasi-Experimental within-Subject Design. International Journal of Nursing Studies, 45, 812-817.
[25] Palese, A., Aidone, E., Dante, A. and Pea, F. (2013) Occurrence and Extent of Bruising According to Duration of Administration of Subcutaneous Low-Molecular-Weight Heparin: A Quasi-Experimental Case-Crossover Study. Journal of Cardiovascular Nursing, 28, 473-482.
[26] Harrison, L., McGinnis, J., Crowther, M., Ginsberg, J. and Hirsh, J. (1998) Assessment of Outpatient Treatment of Deep-Vein Thrombosis with Low-Molecular-Weight Heparin. Archives of Internal Medicine, 158, 2001-2003.
[27] Deakin, D.E., Mishreki, A., Aslam, N. and Docker, C. (2010) Patient Compliance with Extended Low Molecular Weight Heparin Injections Following Hip and Knee Arthroplasty. Hip International, 20, 555-558.
[28] Rubenacker, S., Kaiser, J. and Guschmann, M. (2013) Compliance of Patients Undergoing Thromboprophylaxis with Enoxaparin: The Comfort Study. Der Chirurg, 84, 235-242.
[29] Karlinski, M., Stolarczyk, A., Siuda, M. and Ziolkowski, M. (2006) Compliance with Low Molecular Weight Heparin in Ambulatory Orthopedic Patients. Ortopedia Traumatologia Rehabilitacja, 8, 633-638.
[30] Bergqvist, D., Arcelus, J.I. and Felicissimo, P. (2012) Post-Discharge Compliance to Venous Thromboembolism Prophylaxis in High-Risk Orthopaedic Surgery: Results from the Ethos Registry. Thrombosis and Haemostasis, 107, 280-287.
[31] Wilke, T., Moock, J., Muller, S., Pfannkuche, M. and Kurth, A. (2010) Nonadherence in Outpatient Thrombosis Prophylaxis with Low Molecular Weight Heparins after Major Orthopaedic Surgery. Clinical Orthopaedics and Related Research, 468, 2437-2453.
[32] Sackett, D.L. and Snow, J.C. (1979) The Magnitude of Compliance and Non Compliance. In: Haynes, R.B., Taylor, D.W. and Sackett, D.L., Eds., Compliance in Health Care, Johns Hopkins University Press, Baltimore, 11-22.
[33] Horne, R. and Weinman, J. (1999) Patients’ Beliefs about Prescribed Medicines and Their Role in Adherence to Treatment in Chronic Physical Illness. Journal of Psychosomatic Research, 47, 555-567.
[34] Lebel, B., Malherbe, M., Gouzy, S., Parienti, J.J., Dutheil, J.J., Barrellier, M.T., et al. (2012) Oral Thromboprophylaxis Following Total Hip Replacement: The Issue of Compliance. Orthopaedics and Traumatology: Surgery and Research, 98, 186-192.
[35] Quante, M., Thate-Waschke, I. and Schofer, M. (2012) What Are the Reasons for Patient Preference? A Comparison between Oral and Subcutaneous Administration. Zeitschrift für Orthopädie und Unfallchirurgie, 150, 397-403.
[36] Wilke, T. (2009) Patient Preferences for an Oral Anticoagulant after Major Orthopedic Surgery: Results of a German Survey. Patient, 2, 39-49.
[37] Weitz, J.I., Eikelboom, J.W. and Samama, M.M. (2012) New Antithrombotic Drugs: Antithrombotic Therapy and Prevention of Thrombosis, 9th Ed.: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest, 141, e120S-e151S.
[38] Treasure, T. (2011) Venous Thromboembolism—Reducing the Risk. NICE Guideline.
[39] Turner, A.P., Williams, R.M., Sloan, A.P. and Haselkorn, J.K. (2009) Injection Anxiety Remains a Long-Term Barrier to Medication Adherence in Multiple Sclerosis. Rehabilitation Psychology, 54, 116-121.

Copyright © 2023 by authors and Scientific Research Publishing Inc.

Creative Commons License

This work and the related PDF file are licensed under a Creative Commons Attribution 4.0 International License.