Question

JAR is a 92-year-old man (69.40 kg, 61 in) who suffers from hypertension, dyslipidemia, gastroesophageal reflux, vascular dementia, atrial fibrillation,coronary artery disease, depression, heart failure, diabetes and anxiety. Patient is treated in anticoagulation clinic to treat its atrial fibrillation as it uses Warfarin chronically. JAR uses Aspirin 81 mg, nitroglycerin, Ranitidine, Docusate, Warfarin, Isosorbide Mononitrate, Metoprolol Succinate, Omeprazole, Ranolazine, Simvastatin, Terazosin, Furosemide, Lisinopril and Acetaminofen.

Patient shows up at his appointment at the anticoagulation clinic on 10/10/2019. The pharmacist begins to review his medical record and observes that the patient shows up or to the emergency room on 10/08/2019 with a urine infection for which Septra DS was prescribed for 7 days. El f The teacher's daughter indicates not giving    the antibiotic to her as she was waiting for an appointment with the anticoagulation clinic. However, patient indicates that it continues with symptoms of urine infection including pain and difficulty urinating..

Warfarin Dosage 10/10/2019: 3mg daily except 2 mg on Tuesdays

Pharmacist made dose adjustment to: 2mg daily except 3 mg on Wednesdays and Thursdays so that the   patient will begin the course of treatment with Septra DS.

INR                      10/17/2019       4.97     

                            10/08/2019       3.00     

                            09/27/2019       1.86

                            09/18/2019       1.47

Patient is admitted to the emergency room again for complications of urine infection on 10/17/2019. They call the anticoagulation clinic to see what should be done with Warfarin.

What is the INR target range for this patient?

Why did pharmacist do the dose adjustment on 10/10/2019?

What factors would you consider when evaluating this patient? What drug-drug interactions are present, what is their possible effect on INR? Why?

What recommendation would you make at that   time when you call it an emergency room??

Answer 1

#The level of Warfarin in the blood is elevated to 4.97 which is very high. So it is highly important to stop administration of further warfarin dose. This medication has to be kept on hold .Inj vitamin K is generally administered to reverse it's effects .

#The INR target range for the patient who are in anticoagulant therapy like warfarin is 2.0-3.0

#The pharmacist has done the dose adjustment because the Septra DS can interact with warfarin. This can dramatically increase the level of INR and put the patient under risk of bleeding .So the pharmacist has made adjustments to the dose to maintain the therapeutic level and prevent complications .

#The medication Aspirin can interact with Warfarin and increase the risk of bleeding

Ranitidine also interact with warfarin causing bleeding risk by increasing INR

# The recommendation which has to be made in the emergency room are

• Withhold warfarin
• Administer vitamin K
• Continuous cardiac monitor
• Watch for warfarin toxicity
• Alternative antibiotics to treat infection
• Administration of IV fluids