Warfarin and nonsteroidal antiinflammatory drugs: why not?

Medication overuse and chronic migraine: a critical review according to clinical pharmacology

INTRODUCTION

Chronic migraine is often complicated by medication-overuse headache (MOH), a headache due to excessive intake of acute medications. Chronic migraine and MOH are serious and disabling disorders. Since chronic migraine derives from the progression of originally episodic migraine, the fundamental therapeutic strategy is prevention. This narrative review describes how to try to prevent the development of MOH and how to manage it once it has appeared.

AREAS COVERED

A PubMed database search (from 1988 to January 2015) and a review of published studies on chronic migraine and MOH were conducted.

EXPERT OPINION

In spite of progress in migraine treatment, the prevalence of chronic headaches and MOH has not changed in the course of time. Today, a large number of migraine patients have turned to numerous expert physicians and experienced all sorts of prophylactic treatments without decisive benefits. Their condition seems to have crystallized even more as chronic and intractable. This means that to prevent chronification and MOH, we need more effective drugs and better strategies to use them. In particular, we must detect disease biomarkers and predictive factors for drug response that allow for personalized treatment when migraine is still episodic and make analgesic overuse pointless.

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

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.