Discharge reconciliation after hip surgery in an 82-year-old on four antithrombotic-risk medicines
An 82-year-old woman weighing 55 kg with permanent atrial fibrillation is discharged from hospital after a hip hemiarthroplasty following a fall. Discharge prescription: apixaban 5 mg twice daily, aspirin 81 mg daily, ibuprofen 400 mg three times daily, oxycodone 5 mg every 6 hours as needed, paracetamol 1 g four times daily, atorvastatin 20 mg nightly. Serum creatinine today is 140 micromol/L. She has no history of stroke or ischaemic heart disease and was not on any antithrombotic before admission. She lives alone, uses a walking frame, and her daughter collects the medicines from your community pharmacy and asks whether 'all of this is really necessary'.
1. Which single item on this list carries the greatest immediate risk, and what specific features of this patient make it so?
Read the worked answer
The greatest immediate risk is not one drug but one cluster: full-dose apixaban plus aspirin plus ibuprofen in an 82-year-old, 55 kg woman with a recent fall and surgery - compounded by an apixaban dose that appears to be wrong.
- Apixaban dose: dose reduction to 2.5 mg twice daily is required when at least two of the following are present: age ≥80 years, weight ≤60 kg, serum creatinine ≥1.5 mg/dL (≈133 micromol/L). She meets all three (82 years, 55 kg, 140 micromol/L), so 5 mg twice daily is an over-dose for her.
- Ibuprofen: adds GI mucosal injury and platelet inhibition on top of an anticoagulant, causes fluid retention, and raises blood pressure and AKI risk in an 82-year-old post-operatively. If taken shortly before her aspirin, it also competitively blunts aspirin's irreversible COX-1 acetylation.
- Aspirin: no ischaemic heart disease and no stroke history is documented, so there is no clear secondary-prevention indication; post-operative VTE prophylaxis is already covered by apixaban. It is pure added bleeding risk unless a vascular indication exists.
- Fall risk: walking frame, living alone, post-operative - major bleeding after a fall is the feared outcome.
So the actionable message is: correct the apixaban dose and remove the NSAID, then challenge the aspirin.
2. How would you respond to the daughter, and what exactly do you change or escalate before she leaves the pharmacy?
Read the worked answer
Answer her question directly - 'No, not all of it is necessary, and one of these medicines is at the wrong dose for your mother' - then act in a defined order:
- Do not hand over the apixaban 5 mg as written. Contact the prescriber the same day, state the three dose-reduction criteria met, and request 2.5 mg twice daily. If the prescriber is unreachable and this is the only dose available, supply a small quantity with clear written instructions and a documented follow-up, rather than leaving her without anticoagulation.
- Stop the ibuprofen (prescriber informed, documented). Offer paracetamol - cap at 3 g/day given her age and weight - plus topical NSAID or non-drug measures.
- Query the aspirin, do not silently delete it: 'no documented indication; recommend stopping unless there is a vascular reason I have not seen.'
- Add a laxative (e.g. senna plus docusate): oxycodone, immobility and reduced fluid intake make constipation predictable, and straining after hip surgery is a real problem.
- Counsel: signs of bleeding (black stools, blood in urine, unusual bruising, headache after a fall), missed-dose advice, no NSAIDs without asking, and no need for INR monitoring but renal function will be rechecked.
- Practicalities: large-print labels, a blister/dosette pack with the daughter's involvement, and a documented follow-up call in 1 week.
- Document the intervention, the prescriber contact and the outcome in the patient record.