New Study First to Examine Impact of Anticoagulation Resumption After TBI

PHSR postdoctoral fellow leads interdisciplinary team that finds many patients can benefit from resuming anticoagulation therapy immediately following hospital discharge for traumatic brain injury.

By Malissa Carroll
June 10, 2014

A first-of-its-kind study published by researchers from the University of Maryland School of Pharmacy; University of Maryland School of Medicine; Fairleigh Dickinson University School of Pharmacy; Shock, Trauma and Anesthesiology Research Organized Research Center (STAR-ORC); and IMPAQ International, LLC, has found that, despite an increased risk of bleeding, most patients suffering from a traumatic brain injury (TBI) experience a significant reduction in their risk of stroke as a result of resuming anticoagulation therapy following discharge from the hospital.

“Following TBI, a patient’s risk of stroke substantially increases,” says Jennifer Albrecht, PhD, a postdoctoral fellow in the Department of Pharmaceutical Health Services Research (PHSR) at the School of Pharmacy and the lead author of the study. “Treatment with anticoagulation therapy can reduce the risk of stroke, but carries an elevated potential for bleeding. For older adults with conditions such as atrial fibrillation that are managed with long-term anticoagulation therapy, the situation is even more complicated, as the increased risk of hemorrhage creates a serious dilemma for health care professionals — should anticoagulation therapy be resumed after TBI, and if so, when? Currently, there are no clinical guidelines that address this issue.”

According to the Centers for Disease Control and Prevention, TBI is responsible for 142,000 emergency room visits; 81,500 hospitalizations; and 14,300 deaths among older adults each year. This study — published in the Journal of the American Medical Association (JAMA) Internal Medicine — used a retrospective longitudinal analysis of 10,782 Medicare beneficiaries who were hospitalized with TBI from 2006 to 2009 and received anticoagulation therapy during the month prior to injury to estimate the risk of stroke and hemorrhage associated with anticoagulation therapy resumption following hospital discharge.

All patients included in this study received anticoagulation therapy in the form of warfarin in the month before they suffered TBI. However, in the year following their hospital discharge for TBI, only 55 percent of patients resumed anticoagulation therapy for at least one month.

After examining the data, researchers found that warfarin use following hospital discharge for TBI reduced patients’ risk of ischemic and hemorrhagic stroke by 17 percent. The time at which anticoagulation therapy was resumed did not matter, which suggests that resumption immediately following hospital discharge would benefit most patients.

“Oftentimes, it is the physician’s perceptions of the risks, rather than the benefits, associated with anticoagulation therapy that drives his or her decision to prescribe these medications,” says Albrecht. “Our study not only quantifies the risks and benefits associated with the resumption of anticoagulation therapy following TBI, but provides objective information that will help patients and providers make more informed treatment decisions.”

The study was funded by a grant from the National Institutes of Aging and completed under the guidance of principal investigator Ilene Zuckerman, PharmD, PhD, principal research scientist and managing director at IMPAQ International, LLC, and professor emerita and former chair of PHSR.

“Current clinical guidelines do not provide recommendations regarding the safety or timing of resumption of anticoagulation therapy after TBI in older adults,” says Zuckerman. “The results of this study will inform evidence-based guidelines to improve the management of TBI in older adults, particularly those with co-existing conditions that require anticoagulation.”

Though the results of this study are applicable to most older adults using anticoagulation therapy with TBI, Albrecht warns that there are some individuals who may not benefit from resuming anticoagulation therapy following hospital discharge for TBI. “This study did not include measures of TBI severity. Future studies will need to include such measures to determine if there is a benefit even among severely injured patients,” she says.

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