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Impact of drug interactions when medications are stopped: the often forgotten risks

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Clinical record

An 82-year-old man sustained an unwitnessed mechanical fall within his residential care facility, after which he developed lower back pain and intermittent dizziness. On review by his general practitioner 3 days later, he was found to have extensive bruising of his back, buttocks and thighs. Pathology tests 6 days after the fall showed a haemoglobin level of 69 g/L (reference interval [RI], 122–170 g/L). On arrival at the Alfred Hospital emergency department, he had mild abdominal pain, appeared lethargic and displayed clinical signs of anaemia.

Initial investigations revealed a haemoglobin level of 57 g/L, an international normalised ratio (INR) of > 20 (RI, 0.9–1.3), a prothrombin time of > 200 s (RI, 10.6–15.3 s), and an activated partial thromboplastin time of 95.4 s (RI, 26.0–38.0 s). He also had acute kidney injury, with an estimated glomerular filtration rate of 28 mL/min/1.73 m2 (RI, > 90 mL/min/1.73 m2; baseline, 40 mL/min/1.73 m2).

His medical history included chronic kidney disease, type 2 diabetes mellitus, atrial fibrillation, pulmonary embolism with…