warfarin and Chronic-Pain

Salsalate may offer many advantages over other non-steroidal antiinflammatory agents in patients taking warfarin, however a drug-drug interaction may occur which has not been reported in the medical literature or by the manufacturer of salsalate.. To report a case of warfarin potentiation associated with salsalate treatment, which resulted in bleeding.. Clinical review of the course of a patient, who was stable on warfarin when salsalate therapy was added for chronic pain.. A patient taking stable doses of warfarin for over 1 year (with good control) was prescribed salsalate 3 g/day for pain in his knee and lower back. Approximately 1 month later he presents to the anticoagulation clinic with bruising and an International Normalized Ratio (INR) of 6.8. The patient had a good response to his salsalate therapy and wanted to continue it. The warfarin was held for 3 days and dose lowered by 50 %. His bruising then subsided and he had good control of his warfarin therapy with INRs ranging from 1.9 to 2.2 over the next 4 months. The patient was then lost to follow up.. This case illustrates a strong association between starting salsalate and subsequent potentiation of warfarin, which heretofore has not been reported in the medical literature.

Topics: Aged; Anti-Inflammatory Agents, Non-Steroidal; Anticoagulants; Chronic Pain; Drug Interactions; Hemorrhage; Humans; International Normalized Ratio; Male; Salicylates; Warfarin

Long-acting anticoagulant rodenticides, also called superwarfarins, are known for their greater potency, longer half-life and delayed onset of symptoms. Cases of superwarfarin poisoning can pose a diagnostic and clinical challenge due to a wide array of presentations and prolonged severe coagulopathy requiring months of high-dose oral vitamin K therapy. The most common presentation of long-acting anticoagulant rodenticide poisoning is mucocutaneous bleeding, with other common presentations including haematuria, gingival bleeding, epistaxis and gastrointestinal bleeding. We discuss a case of deliberate self-poisoning with long-acting anticoagulant rodenticides presenting with haematuria and coagulation values above measurable limits. This case is important as it required immediate and maintenance therapy in order to prevent profound bleeding, as well as the evaluation of the patient's psychosocial factors to ensure medical compliance and to prevent refractory complications or repeated self-harm.

Topics: Abdominal Pain; Anticoagulants; Antifibrinolytic Agents; Anxiety Disorders; Blood Coagulation; Blood Coagulation Disorders; Chronic Pain; Comorbidity; Delayed-Action Preparations; Gastrointestinal Hemorrhage; Hematuria; Humans; Male; Middle Aged; Referral and Consultation; Suicide, Attempted; Treatment Outcome; Vitamin K; Warfarin

Topics: Atrial Fibrillation; Awards and Prizes; Bipolar Disorder; Chronic Pain; Delivery of Health Care; General Practice; Humans; Organizational Innovation; Patient Education as Topic; Patient Safety; Referral and Consultation; Risk Management; United Kingdom; Warfarin

The emergency department (ED) serves as the primary gateway for acute care and the source of health care of last resort. Emergency physicians are commonly expected to rapidly assess and treat patients with a variety of life-threatening conditions. However, patients do refuse recommended therapy, even when the consequences are significant morbidity and even mortality. This raises the ethical dilemma of how emergency physicians and ED staff can rapidly determine whether patient refusal of treatment recommendations is based on intact decision-making capacity and how to respond in an appropriate manner when the declining of necessary care by the patient is lacking a basis in informed judgment. This article presents a case that illustrates the ethical tensions raised by the refusal of life-sustaining care in the ED and how such situations can be approached in an ethically appropriate manner.

Topics: Adult; Anticoagulants; Cerebral Veins; Chest Pain; Chronic Pain; Emergency Service, Hospital; Fatal Outcome; Female; Flank Pain; Headache Disorders; Humans; Narcotics; Pulmonary Artery; Treatment Refusal; Venous Thrombosis; Vision Disorders; Warfarin