Am Care in Singapore

Yesterday I was able to briefly visit the am care clinics at SGH, more specifically the warfarin clinic.  It is very similar to what happens in the US and is done in person.  The clinic is run by a pharmacist working under protocol as it is in the States.  Patients perform a typical INR test and when the result is in, they are called into the room for evaluation.  The most important difference from the classroom for me at SGH was pharmacogenomic.  It has been well studied and taught to us, but usual American dosing and management of subtherapeutic INRs are too extreme for a predominantly Asian population.  As I learned yesterday, increasing the total weekly warfarin dose by 5% (instead of 10%) is normally sufficient to get the increase you want in the INR.

Warfarin only comes in 3 doses in Singapore so with my first patient I thought I had caught noncompliance with the pill coloring but the patient was actually accurate with the dosing!  1 mg = brown, 3 mg = blue, and 5 mg = pink.  The other pharmacists here were amazed that we have so many doses of warfarin in the US!  Another interesting thing here is that the clinic never gives refills on warfarin.  They always only prescribe just enough to make it to the next clinic visit to ensure the patient returns, and for the most part, the patient does come back for their appointments, which is not always the case in the US.  Otherwise, the practice here is similar to the US since they also follow the CHEST guidelines.  Next week will be the MTM clinic!