Drug Prescribing and Monitoring 2

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Case 1 of 10Drug Prescribing and MonitoringDrug interactions

A 70-year-old woman with rheumatic moderate mitral stenosis and permanent atrial fibrillation is seen for 2 weeks of painful swallowing. She takes warfarin 4 mg daily (INR stable between 2.0 and 3.0 for several years; 2.5 last week), digoxin 0.125 mg daily, and inhaled fluticasone-salmeterol and tiotropium for COPD. She has no known drug allergies. On examination, white plaques are present on the tongue and posterior pharynx. Upper endoscopy confirms Candida esophagitis, and a 14-day course of oral fluconazole is planned. eGFR is 62 mL/min/1.73 m² (greater than 60).

Heart rate	84/min, irregularly irregular
Respiratory rate	16/min
Temperature	36.9 °C
O2 saturation	95%, room air
Blood pressure	128/76 mm Hg

Question 1 of 30

Which of the following are the most appropriate actions before and after starting fluconazole?

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AReplace fluconazole with miconazole oral gel

BReduce warfarin dose empirically by 25% to 50%

CReplace fluconazole with itraconazole PO

DIncrease warfarin dose empirically by 25%

EContinue warfarin at the current dose and recheck INR in 4 weeks

FStart vitamin K PO daily prophylactically

GHold warfarin for the duration of fluconazole therapy

HCheck INR within 3 to 5 days of starting fluconazole

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