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A 52-year-old man presents to the ED with a complaint
of rectal bleeding and hematuria. He has a
medical history significant for atrial fibrillation
diagnosed 10 years ago and states that he takes
metoprolol as well as warfarin for this condition.
Upon examination, you find that his blood pressure
is 122/78, his pulse is 84, his respiratory rate is 18,
and his O2 saturation is 98% on room air. He has an
irregularly irregular heart rhythm, gingival bleeding,
and some bruises on his extremities. He has a
positive fecal occult blood test, and laboratory
studies return showing an international normalized
ratio (INR) of 16.5.
1. You order that the patient’s warfarin be held.
Which of the following is the most appropriate
additional intervention at at this time?
(A) repeat INR measurement as an outpatient
in 5 days
(B) admit the patient to the hospital and
conduct serial INR measurements
© administer vitamin K1
(D) administer fresh frozen plasma
(E) administer vitamin K1 and fresh frozen
plasma
2. Reviewing the patient’s medication list, you
note that he mentions a “medication for depression”
but does not recall the name. Which of
the following is most concerning given the
patient’s current condition?
(A) amitriptyline
(B) trazodone
© fluoxetine
(D) venlafaxine
(E) imipramine
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can you explain the second part please
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guys cant it b E for first part..i m confused between D/E?? his inr is too high..though fresh frozen plasma is appropriate for current situation but if we give vit k along it vl help in synthesising clotting factors n prevent further bleeding episodes... give ur opinion???
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ANSWERS ARE... E ...AND... C...
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Can you explain 2 answer C...please...I am not following...
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kaplan says no life threatening bleed and inr 20= ffp + vit k
???
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E..
C..
This patient has a markedly supratherapeutic
INR and clinical evidence of bleeding.
Discontinuation or dosage reduction of warfarin
is an appropriate intervention by itself in
patients when ----------->an INR less than 5.0 or in patients
without signs of bleeding.
In patients withbleeding or with an INR greater than 5.0, -------->further interventions are indicated. So, here---
Vitamin K1 administration provides a more
rapid reversal of the anticoagulation caused by
warfarin, but it takes 6–8 hours to begin having
an effect and up to 24 hours to achieve its maximal
effect.
and
Immediate reversal may be
obtained by the administration of fresh frozen
plasma intravenously in addition to vitamin
K1. (Cecil Textbook of Medicine, p. 163).
Elimination of warfarin from the body
depends on the activity of cytochrome P450 in
the liver. Therefore, drugs which inhibit
cytochrome P450 will lead to a reduction in warfarin
clearance and will consequently lead to an
increase in the anticoagulation effect obtained
from a specific dose of warfarin.
drugs which inhibit cytochrome P450 ---
selective serotonin reuptake inhibitors (SSRIs),
cimetidine,
fluoroquinolones,
metronidazole,
isoniazid, amiodarone, quinidine, erythromycin,
cyclosporine, HIV protease inhibitors, and
azole antifungals.
Amitriptyline, trazodone, venlafaxine, and imipramine neither inhibit nor
induce cytochrome P450 activity.
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