the follow-up appointment 2 days later, the extraction…
Pharmacology questions in the ADC written exam test applied prescribing decisions, not rote recall of drug names. This high-difficulty vignette tests your ability to work through clinical details and arrive at the correct management.
Mrs. Fatima Al-Rashid, a 75-year-old woman, presents for a routine dental check-up. She takes warfarin for atrial fibrillation. During examination, you discover a mobile, tender lower incisor (tooth 41) that she wishes to have removed. She also mentions she has been applying miconazole oral gel for oral thrush diagnosed by her GP last week. Her other medications include ramipril 5 mg and frusemide 20 mg daily. Her INR from 3 days ago was 2.6, but she does not have a more recent result. At the follow-up appointment 2 days later, the extraction site is healing well with no bleeding. However, the patient mentions she has been feeling increasingly unwell with nausea since yesterday. Her INR is now 5.8. What is the most likely explanation for the INR rise?
- A. She inadvertently took extra warfarin doses due to confusion about her postoperative medications
- B. The extraction procedure itself caused a transient rise in INR through tissue factor release
- C. Reduced oral intake after the extraction has altered warfarin absorption
- D. The miconazole oral gel continues to inhibit warfarin metabolism, progressively increasing the INR
- E. The paracetamol prescribed for post-extraction pain has interacted with warfarin to increase the INR
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Miconazole (including oral gel applied to the oral mucosa) is absorbed systemically and inhibits CYP2C9, the primary enzyme responsible for warfarin metabolism. This interaction progressively increases the INR and can lead to dangerously elevated levels. The patient must be urgently referred to her medical practitioner for INR management. This case reinforces the importance of recognising drug interactions when managing patients on warfarin — the interaction identified in Q2 has now caused a clinical complication.
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