The National anticoagulation program founded in 2012 by Ministry of Health in Saudi Arabia. It organized by General Administration of Pharmaceutical care. It required of domestic and international hospital accreditation institutions. The program is crucial to prevent medication drug problems, improve patient morbidity and mortality with avoiding addition economic burden on health care system. The program consisted all patient hospitalization stages emergency visit, ambulatory care visit, hospital admission, and discharge. It started with governmental institutions then expand to primary care centers and privates institutions. The strategic program plan for coming years with policy and procedures and key performance indicators to follow the programimplementation. The program is currently is a different national wise and without resembling at Gulf or Middle East countries. Anticoagulation program highly demands with a crucial role of pharmacist of lead and implementing the new program at Ministry of Health institutions in Saudi Arabia

Keywords: Anticoagulation; Pharmaceutical Care; Pharmacy; Ministry of Health; Saudi Arabia


In between 2008-2012, the author was director of regional Drug Information Center at the biggest hospital of MOH (1400) beds. The authors and his team established Anticoagulation program at the hospital. The program consisted of six Anticoagulation guidelines the team designed them as physician order form. Any physician used to fill the form as a prescription. They included physician of heparin, physician order of warfarin, physician order of Anticoagulation bridging therapy, physician order of heparininduced thrombocytopenia Therapy, and Physician order of prevention thrombosis. Each format had an indication, medication listed as the first line, seconded line and third option, each with specific drug dosing in normal function and kidney failure. All those orders approved by hospital pharmacy and therapeutic committee, medical director, and CEO of the hospital. Also, the drug information center made educational material for any patient received Anticoagulation medication. The program activated in 2010 and still running until now.

The benefit of Pharmacy Anticoagulation Program

The national and international institutions of hospital accreditation required to implement the anticoagulation program [1-2]. In national data in United Sated of America, more than millions of patient records either hospital admission, emergency or ambulatory care visit had reviewed of Venous thrombosis risk over five years 2001-2005 and compliance of 6th American College of Chest Physician guidelines of prevention of venous thromboembolism Anticoagulation program are very high demand. The authors found more 50% non-adherence of the guidelines with several types of non-compliance started late, started late and ended early, or ended early [3]. A large multicenter study with more than thirty countries and 68 thousand medical or surgical patients. The author found 64% at risk for VTE for surgical patient and 59% of them received ACCP recommended VTE prophylaxis, and 42% at risk for VTE for amedical patient and 40% of them received ACCP recommended VTE prophylaxis [4]. In a local study, the author found a significant difference in the case facilities between whom received VTE prophylaxis and without prophylaxis [5]. With the high risk of mortality of VTE, most of the counties started the very comprehensive anticoagulation program and decreased the morbidity and mortality of that are events. In the systemic review study through Cochrane database, the authors found there is a significant improvement of VTE prescribing by education and alert system intervention [6]. The outcomes of the implementation of anticoagulation guidelines in Saudi Arabia measured through a study conducted at medical intensive care unit. The authors found a significant reduction incidence of VTE [7]. Also, the economic burden is very crucial, the average cost per each VTE events in range (898-20,994) USD while the estimated cost avoidance of anticoagulation implementation program in Saudi Arabia was (27,370,492.3/year) USD [8-9].

The Pharmacist-Directed Anticoagulation Program

All mention anticoagulation guidelines implemented by physicians. While the potential pharmacist role of coordinate and implement anticoagulation protocols at hospital practice. The pharmacist organizes the Anticoagulation program well established in several counties. The pharmacist organizes the Anticoagulation program well established in several counties. For instance; in the United State of America (USA) started the pharmacist-directed anticoagulation program in the 1980s with several studies randomized controlled or observational methodology. The studies showed significant improvement in patient clinical outcomes than a physician. It showed better improvement of the anticoagulation therapeutic time range, much adherence to anticoagulation guidelines, more patient compliance, much patient satisfaction of the services, fewer complications of anticoagulation therapy, avoid the unnecessary economic burden on health care system, and the ability of the pharmacist to provide pharmacy based anticoagulation services [10-20]. In addition to another country including South Korea, Australia, Canada, Malaysia, Kenya, Thailand, New Zealand, Singapore, and United Kingdom [21-29]. Moreover, the two only of Middle East, countries like Qatar and recently Sudan started anticoagulation program [30-32]. They implemented the services and measured the program outcome with a plan of expanding the services. All the previous studies showed the implemented same services with individual and separated at their institutions. However, our program had the same content, policy, and procedures, but it is national wise implementation through MOH, coordinated, and combined through over several committees. Locally, the study conducted at East Province of Saudi Arabia about the pharmacistmanaged anticoagulation clinic. The authors found better than traditional practice, reduction of adverse events of anticoagulation, and high patient satisfaction of the services [33].

Pharmacy Anticoagulation Program in Kingdom of Saudi Arabia

In late 2012, the Minister of Health assigned the author as general manager of general administration of pharmaceutical care. The author updated the strategic planning of pharmaceutical care and started more thirty-pharmacy practice and clinical pharmacy programs, the Anticoagulation program among them [34-36]. The central committee of Anticoagulation formulated consisted of clinical pharmacists from different regions in Kingdom of Saudi Arabia. The central committee updated previous Anticoagulation formats based on the last issue of American College of Chest Physician (ACCP) thromboembolic disorder guidelines and Saudi Practice guidelines of Deep Vein Thrombosis (DVT) prophylactics for medical and surgical populations [37-38]. There is three type of anticoagulation committees; central pharmacy anticoagulation committee at MOH, the hospital pharmacy anticoagulation community and the team at the very hospital. Also, may organize regional pharmacy anticoagulation committee to supervise all hospital committee at each region with almost as the same as functions and works at their area as explored in Table 1. The central committee setupaplan for five years, and policy and procedures of the anticoagulation hospital committee as explored in Table 1 and Table 2. Moreover, the committee finished of an anticoagulation key performance indicator for following program implementation. The example of the year 2012-2014 explored in Table 3. The program as national level is new and the author not familiar with any national program wise at Gulf or the Middle Eastcountries


Pharmacy anticoagulation program is part of clinical pharmacy services provided to the patient at MOH health care institution. The program is essential for hospital national and international accreditation. The program is highly demanding at Ministry of Health organization to reduce the patient morbidity and mortality in Saudi Arabia.

Table 1: Type of Pharmacy Anticoagulationcommittees
Table 2: Strategic plan of pharmacy anticoagulation program
Table 3: Hospital anticoagulation program Key Performance Indicators
  1. (2016) Saudi Center Board of Accreditation for Healthcare Institutions (CBAHI). Medication management system.
  2. (2017) Comprehensive Accreditation Manuals. Joint Commission Resources.
  3. Yu HT, Dylan ML, Lin J, Dubois RW (2007) Hospitals’ compliance with prophylaxis guidelines for venous thromboembolism. Am J Heal Pharm 64(1): 69-76.
  4. Cohen AT, Tapson VF, Bergmann JF, Goldhaber SZ, Kakkar AK, et al. (2008) Venous thromboembolism risk and prophylaxis in the acute hospital care setting (ENDORSE study): a multinational cross-sectional study. Lancet 371(9610): 387-394.
  5. Essam AE, Sharif G, Al-Hameed F (2011) Venous thromboembolism-related mortality and morbidity in King Fahd General Hospital, Jeddah, Kingdom of Saudi Arabia. Ann Thorac Med 6(4): 193-198.
  6. Kahn SR, Morrison DR, Emed J, Tagalakis V, Shrier I (2010) Interventions for implementation of thromboprophylaxis in hospitalized medical and surgical patients at risk for venous thromboembolism. Cochrane Database of Systematic Reviews, Chichester, John Wiley & Sons, Ltd.
  7. Al-Otair HA, Khurshid SM, Alzeer AH (2012) Venous thromboembolism in a medical intensive care unit. The effect of implementing clinical practice guidelines. Saudi Med J 33(1): 55-60.
  8. Dobesh PP (2009) Economic Burden of Venous Thromboembolism in Hospitalized Patients. Pharmacotherapy 29(8): 943-953.
  9. Alomi YA, Alharbi E, Alshayban D, Khoshaim M, Alhowasi M, et al. (2014) Population-based cost-efficiency simulation of partial versus complete thromboprophylaxis in hospitalized patients in Saudi Arabia: Application of a British model. Value in Health 17(7): A533.
  10. Gray DR, Garabedian-Ruffalo SM, Chretien SD (1985) Cost-justification of a clinical pharmacist-managed anticoagulation clinic. Drug Intell Clin Pharm 19(7-8): 575-580.
  11. Cohen IA, Hutchison TA, Kirking DM, Shue ME (1985) Evaluation of a pharmacist-managed anticoagulation clinic. J Clin Hosp Pharm 10(2): 167-175.
  12. Conte RR, Kehoe WA, Nielson N, Lodhia H (1986) Nine-year experience with a pharmacist-managed anticoagulation clinic. Am J Hosp Pharm 43(10): 2460-2464.
  13. Wilt VM, Gums JG, Ahmed OI, Moore LM (1995) Outcome analysis of a pharmacist-managed anticoagulation service. Pharmacotherapy 15(6): 732-739.
  14. Lewis SM, Kroner BA (1997) Patient survey of a pharmacist-managed anticoagulation clinic. Manag Care Interface 10(11): 66-70.
  15. Holden J, Holden K (2000) Comparative effectiveness of general practitioner versus pharmacist dosing of patients requiring anticoagulation in the community. J Clin Pharm Ther 25(1): 49-54.
  16. Lodwick AD, Sajbel TA (2000) Patient and physician satisfaction with a pharmacist-managed anticoagulation clinic: implications for managed care organizations. Manag Care 9(2): 47-50.
  17. Bond CA, Raehl CL (2004) Pharmacist-provided anticoagulation management in United States hospitals: death rates, length of stay, Medicare charges, bleeding complications, and transfusions. Pharmacotherapy 24(8): 953-963.
  18. Gray DR, Garabedian-Ruffalo SM, Chretien SD (2007) Cost-justification of a clinical pharmacist-managed anticoagulation clinic. Ann Pharmacother 41(3): 496-501.
  19. Lee PY, Han SY, Miyahara RK (2013) Adherence and outcomes of patients treated with dabigatran: pharmacist-managed anticoagulation clinic versus usual care. Am J Heal Syst Pharm 70(13): 1154-1161.
  20. Hicho MD, Rybarczyk A, Boros M (2016) Interventions unrelated to anticoagulation in a pharmacist-managed anticoagulation clinic. Am J Heal Syst Pharm 73(11 Suppl 3): S80-S87.
  21. Choe HM, Kim J, Choi KE, Mueller BA (2002) Implementation of the first pharmacist-managed ambulatory care anticoagulation clinic in South Korea. Am J Heal Syst Pharm 59(9): 872-874.
  22. Jackson SL, Peterson GM, Bereznicki LR, Misan GM, Jupe DM, et al. (2005) Improving the outcomes of anticoagulation in rural Australia: an evaluation of pharmacist-assisted monitoring of warfarin therapy. J Clin Pharm Ther 30(4): 345-353.
  23. Bungard TJ, Gardner L, Archer SL, Hamilton P, Ritchie B, et al. (2009) Evaluation of a pharmacist-managed anticoagulation clinic: Improving patient care. Open Med 3(1): e16-21.
  24. Hasan SS, Shamala R, Syed IA, Basariah N, Chong DW, et al. (2011) Factors affecting warfarin-related knowledge and INR control of patients attending physician- and pharmacist-managed anticoagulation clinics. J Pharm Pr 24(5): 485-493.
  25. Manji I, Pastakia SD, Do AN, Ouma MN, Schellhase E, et al. (2011) Performance outcomes of a pharmacist-managed anticoagulation clinic in the rural, resource-constrained setting of Eldoret, Kenya. J Thromb Haemost 9(11): 2215-2220.
  26. Saokaew S, Sapoo U, Nathisuwan S, Chaiyakunapruk N, Permsuwan U (2012) Anticoagulation control of pharmacist-managed collaborative care versus usual care in Thailand. Int J Clin Pharm 34(1): 105-112.
  27. Shaw J, Harrison J, Harrison J (2014) A community pharmacist-led anticoagulation management service: attitudes towards a new collaborative model of care in New Zealand. Int J Pharm Pr 22(6): 397-406.
  28. Chua WB, Cheen HH, Kong MC, Chen LL, Wee HL (2016)  Modeling the cost-effectiveness of pharmacist-managed anticoagulation service for older adults with atrial fibrillation in Singapore. Int J Clin Pharm 38(5): 1230-1240.
  29. Dowling T, Patel A, Oakley K, Martin Sheppard (2016) Assessing the impact of a targeted pharmacist-led anticoagulant review clinic. Clinical Pharmacist.
  30. Elewa H, Jalali F, Khudair N, Hassaballah N, Abdelsamad O, et al. (2016) Evaluation of pharmacist-based compared to doctor-based anticoagulation management in Qatar. J Eval Clin Pr 22(3): 433-438.
  31. Elewa HF, AbdelSamad O, Elmubark AE, Al-Taweel HM, Mohamed A, et al. (2016) The first pharmacist-managed anticoagulation clinic under a collaborative practice agreement in Qatar: clinical and patient-oriented outcomes. J Clin Pharm Ther 41(4): 403-408.
  32. Ahmed NO, Osman B, Abdelhai YM, El-Hadiyah TMH. Impact of clinical pharmacist intervention in anticoagulation clinic in Sudan. Int J Clin Pharm. doi: 10.1007/s11096-017-0475-x
  33. Dib JG, Mohammed K, Momattin HI, Alshehri AM (2014) Implementation of Pharmacist-Managed Anticoagulation Clinic in a Saudi Arabian Health Center. Hosp Pharm 49(3): 260-268.
  34. (2017) About the Ministry. Strategy. Ministry of Health Portal, Kingdom of Saudi Arabia.
  35. Alomi YA, Alghamdi SJ, Alattyh RA (2015) Strategic Plan of General Administration of Pharmaceutical Care at Ministry of Health in Saudi Arabia 2012 – 2022. JPharm Pharm Scien 1(13): 1-8.
  36. Alomi Y (2015) National Pharmacy Practice Programs at Ministry of Health in Saudi Arabia. Journal of Pharm and Pharmaceutical Science 1(2): 17-8.
  37. Al-Hameed FM, Al-Dorzi HM, Abdelaal MA, Alaklabi A, Bakhsh E, et al. (2017) The Saudi clinical practice guideline for the prophylaxis of venous thromboembolism in long-distance travelers. Saudi Medical Journal 38(1): 101-107.
  38. Al-Hameed FM, Al-Dorzi HM, Abdelaal MA, Alaklabi A, Bakhsh E, et al. (2016) The Saudi clinical practice guideline for the prophylaxis of venous thromboembolism in medical and critically ill patients. Saudi Medical Journal 37(11): 1279-1293.