A 45 year old woman presents to your clinic with history of intermittent epistaxis. Of late, this has become more frequent. The patient has a history of atrial fibrillation for which she has been taking aspirin as recommended by her cardiologist. She has no other past medical history. The patient also takes over the counter medications such as Vitamin b-complex which she thinks keeps her from getting tired. She says she also takes about 4 grams of Omega 3 fatty acids to keep “her heart healthy” and Ginkgo biloba to slow the “ageing of her brain”. Her laboratory tests reveal normal complete blood count. Prothrombin time and partial thromboplastin time are with in normal limits. Which of the following is your next step in managing this patient’s recurrent epistaxis?
A. Advise her to discontinue omega 3 fatty acids.
B. Discontinue Aspirin
C. Advise her to stop both Omega 3 fatty acids and Ginkgo biloba
D. Advise her to stop Ginkgo biloba
E. Advise her to stop Vitamin B-complex
C
Ans. C
Advise to discontinue both omega 3 fatty acids and ginkgo biloba ( Ans. C). Ginkgo biloba potentiates aspirin by increasing the bleeding time. Omega 3 fatty acids in large doses can also prolong the bleeding time by decreasing the platelet aggregation. Since this patient is having recurrent epistaxis, it is advisable to discontinue both of them at this time and observe.
Ans. A is sub-optimal management.
Ans. B is incorrect. The patient has “lone” atrial fibrillation and she requires aspirin to reduce her stroke risk.
Ans. D is sub-optimal management.
Ans. E is incorrect. B-complex has no effect on bleeding time or platelet aggregation.
c
d?
Thats hogwash
u must stop EVERYTHING that inhibits platlet function including ASA.; until symptoms subside. You should be shot if you dont stop ASA also
Bad Question
You must understand the relative importance of each drug presented in the question. You must weigh the risk versus benefit of stopping a drug. You must also assess the severity of the symptoms. In this case, she has minor bleeding in the form of epistaxis. If this were a major bleeding, it is justified to stop all the anti platelet drugs. It is not just the ASA but it is the interaction between Ginkgo, ASA and Omega that is increasing her risk of bleeding. Omega fatty acids and Ginkgo biloba are adjuncts that the patient is using at her own discretion. So, Ginkgo and omega must be stopped first. ASA is used in this patient for a reason – it is being used for stroke prevention because she has lone atrial fibrillation. Stopping ASA would increase her stroke risk and it is an unacceptable step. If the patient were to suffer a stroke, medicolegally, your license could be “shot” for failing to balance risk versus benefit of your intervention. Similar language is used so that you can understand the concept better – no “pun” intended!
She is activly bleeding…..stoping the asa for a 2 week period until the bleeding stops is NOT a licence decision.
The question mentions a “clinic” presentation with “history” of intermittent epistaxis. There is no active bleeding. It is important to recognize the nature of presentation . If the patient were to bleed heavily and actively, she would be present in the ER not in the office
Dude you should take over Fishy @ kaplan!
Archer is the best…Epistaxis is like menorrhagia — mucosal bleeding. Do you stop Aspirin in a lady with menstrual bleeding to prevent STROKE? lol, i’m afraid not. Risk Vs Benefit. She needs the aspirin!
good one!
I agree with stopping aspirin , and this is a really bad q’s as my friends already said so , aspirin makes the plateletts inactive right off the bed and since this person is encountering frequent episodes of bleeding he might go eventually very low on Hb , isn’t that a risk?
i remember very well from Dr.Goljan step1 pathology that aspirin makes all the plateletts inactive , every single one of them ! so we don’t need vit E or omega 3 or ginko to make that worse but with aspirin in place we are already having trouble here! so if the epistaxis are getting more frequent i suggest we take care of that first (for the patient convenient and safety), why not putting the patient on heparine or warfarine instead ?
thats what i think let me know if im wrong please