Reevaluating the Safety of Concurrent Warfarin and Ibuprofen Therapy: A Case Report

Abstract

Objective: To describe a case of subclinical bleeding and elevated international normalized ratio (INR) associated with the concomitant use of ibuprofen and warfarin. Case Summary: A 74-year-old white woman receiving warfarin for a history of cerebrovascular accident and deep-vein thrombosis with concomitant chronic obstructive pulmonary disease, hypertension, congestive heart failure, coronary artery disease, osteoarthritis, and erosive esophagitis developed significant elevation of the INR after the addition of ibuprofen to her medication regimen. The patient experienced a decrease in hemoglobin concentration, asymptomatic hypotension, and increased blood urea nitrogen/creatinine ratio. Limited physical examination failed to locate a source of bleeding. Discussion: The pharmacokinetic and pharmacodynamic interactions involving nonsteroidal antiinflammatory agents and warfarin are well documented. Limited data from healthy volunteers and patients without complex medical problems suggest that ibuprofen and warfarin may be given concomitantly with relative safety. This report describes an elderly patient with multiple medical problems, treated with numerous medications, including warfarin, who developed signs suggestive of subclinical bleeding and an INR of 14.3 after the addition of low-dose ibuprofen. Conclusions: Concomitant use of ibuprofen and warfarin should be avoided in elderly patients with complex medical problems treated with multiple medications.