1. Your Nomination - Please briefly describe in your own words the question about a health care test or treatment that interests or concerns you:

"Chronic pain management for persons receiving anticoagulants, especially those on warfarin."

2. Why do you think your question is important? (you may select more than one category if appropriate)

 My question relates to a very common disease or problem
 People with this disease or problem have considerable health or financial hardships
 There is uncertainty about how well the test, treatment, or intervention works
 There is significant potential for side effects/harms using this test, treatment, or intervention
 Funding of this test, treatment, or intervention is uncertain or variable
 There is unequal access or application of this health care intervention across providers
 There is potential for cost savings from better information on this subject
 This is a new technology/development
 There is new evidence of clinical and/or cost effectiveness for this test, treatment, or intervention
 Other

3. What illness or health condition is related to your question? (You can also specify a particular health-promoting activity, such as breast-feeding)

Pain medications, including acetaminophen and NSAIDS, are used by large nubmers of people and also contraindicated by patients taking warfarin. However, warfarin patients often have other comorbidities that may necessitate the use of pain medicines. Warfarin is an effective therapy but has a narrow therapeutic index: too high a dose can result in major bleeding and too low a dose can result in stroke. Both can be fatal. Warfarin is the drug with the second highest cause for emergency dept visits. A significant cause of warfarin ADE are due to drug interactions that result in changing levels of warfarin. NSAIDS increase bleeding and therefore can increase the effect of warfarin. Acetaminophen has also had many reports of increasing ADE in warfarin patients. So what should clinicians prescribe for their warfarin patients who need pain meds. Clinicians need help in making decisions in this area.

4. What group(s) or patients does your question apply to?

Patients who are on warfarin and need to pain medications. Warfarin is given to those patients with atrial fibrillation, deep vein thrombosis, prostethic heart valves, and orthopedic surgery, to name a few. indications. Warfarin is prescribed to more than 2 million patients each year.

5. What is the specific purpose of the health care test or treatment you have a question about? (mark all that you think apply)

Identification of a disease or condition:
 Screening or diagnosis/identification for a particular disease, or risk assessment for a disease
 Risks or harms that can come from a disease identification tool or test
 Diagnostic tests and tools
 Diagnosis of co-occurring diseases
 Intervention (such as a drug treatment, therapy, device)
 Management of a condition or particular system of care
 Delivery of a health service
 Referral
 Risks or harms associated with treatment of a disease or condition
 Prevention or health promotion
 Specific population health concerns, such as ethnic group or gender
 Other
 Dont know

6. Does your question include a comparison of different health care approaches?

Yes
If yes, please list what you would like to see compared:
The question implies that there might be a recommendation of what pain medication patients on warfarin can take.

7. Desired Health Improvements: If you question focuses on:

Identification of a particular disease or condition, what improvements in identification or diagnosis would you like to see?


Treatment of a particular disease or condition, what improvements in patient symptoms or problems would you like to see? The goal would be to be able to document from the literature, those pain medications that result in a serious ADE in warfarin patients; to list pain medications that do not result in serious ADE in warfarin patients and to articulate gaps and recommend additional studies. The improvements would be a reduction in hospitalizations and emergency dept visits by warfarin patients.

8. Harms: Are there risks, side effects, or harms you are concerned about? If yes, please specify what those are:

The risks are major bleeding or stroke as a result of taking pain medicaitons with warfarin. These are serious ADE that result in hospitalization, emergency dept visits or death.

9. Based on your answers to the previous questions, what research question(s) would you like to have answered?

"Chronic pain management for persons receiving anticoagulants, especially those on warfarin.”

10. Are there health-care focused, disease-focused, or patient-focused organizations that you see as being relevant to this issue? Who do you think we should contact as we consider your nomination?

University of Alabama CERT American Heart Association The issue of warfarin interactions came up as a top priority at the last CERT Steering Committee meeting in March 2008.

11. Other Information About You (OPTIONAL) In order to help us understand the context of your health care question, it would be helpful to know more about you. The answers you give will not influence the progress of your suggestion. Thank you.

a. Please choose a description that best describes your role or perspective: (you may select more than one category if appropriate)
Researcher

b. Is there any other information about you that is relevant to your question?
Not applicable

c. Are you making a suggestion as an individual or on behalf of an organization?
 Individual
 Organization