A 74 year old female was recently discharged from the hospital with pneumonia. The latest INR was 2.1.
- Aspirin 81 mg daily
- Warfarin 2.5 mg daily
- Lamotrigine 25 mg BID
- Ranitidine 150 mg daily
- Carafate 1 gram twice daily
- Loperamide as needed (just recently started)
- Ramipril 5 mg daily
- Amlodipine 10 mg daily
- Metoprolol 100 mg twice daily
About 3 days following discharge she begin to develop foul smelling diarrhea. It continued for another 2-3 days before going into the clinic to get assessed.
Diagnosis was made as C. Diff infection. She was initiated on metronidazole for 10 days to treat the suspected infection. On day 7 of antibiotic therapy, the patient has a nose bleed that she cannot resolve. She goes to a local urgent care clinic where an INR was checked and it was 9.4.
So, we must ask the question as to what would’ve prevented the warfarin and metronidazole interaction from getting out of control and putting our patient at risk? Taking warfarin and metronidazole will usually result in increased concentrations of warfarin and increase the risk of elevated INR. Checking an INR on day 3-5 would have been a plausible option and may have been able to prevent this interaction from getting out of hand.
Another option that I occasionally see in practice is preemptive dose reduction of warfarin. They recommend about a 30-35% reduction in the warfarin dose for the warfarin and metronidazole interaction. Here’s a small study with a little further reading on that.
Another alternative would be to identify if the patient is a candidate for a newer oral anticoagulant that might have lower risk of interactions in the future.
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Pharmacist Statistics Study Guide (great resource for any pharmacist seeking a BPS board certification)