Table 3 Vitamin K antagonist case vignettes

1. 82-year-old woman at home with pancreatic carcinoma.

Atrial fibrillation, arterial hypertension, TIA, NIDDM

Acenocoumarol (VKA)

Comedication: amitriptyline retard 1dd 50 mg, amlodipine 1dd 5 mg, atorvastatin 10 mg, bisoprolol 1dd 2.5 mg, candesartan 1dd 16 mg, metformin 1dd 500 mg, pantoprazole 1dd 40 mg, temazepam 1dd 10 mg a.n.

Seventeen days before death metformin is increased to 2dd 500 mg because of an increase in HbA1c. Ten days before death she is drowsy and nauseous. Metformin is stopped and glimepiride 1dd 2 mg is started. Amitriptyline, amlodipine and atorvastatin is stopped. The candesartan is decreased to 1dd 8 mg. Three days later she has a glucose of 1.8 mmol/L (32.4 mg/dL) and glimepiride is stopped. Three days later metformin is restarted at 2dd 250 mg because of a glucose of 8.6 mmol/l (154.8 mg/dL).

She deteriorates, and three days later she is unconscious. All medication (including the acenocoumarol) is stopped and morphine suppository 4dd 20 mg is started. She dies the following day.

2. 95-year-old woman at home with arterial hypertension, atrial fibrillation, COPD and dementia.

Acenocoumarol (VKA)

Comedication: cholecalciferol 1dd 800 IE, furosemide 1dd 80 mg, digoxin 1dd 0.125 mg, losartan 1dd 25 mg, temazepam 1dd 10 mg a.n.

She suffers from dyspnea and therefore the furosemide is increased with 40 mg/day extra for ten days. She frequently falls and suffers from hematomas. The acenocoumarol is stopped. Two days later she has fever and dyspnea. All other medication is stopped, she receives some morphine and midazolam and passes away.

3. 67-year-old man at home with metastatic lung carcinoma. Previous history of arterial hypertension, peripheral arterial disease and NIDDM.

Acenocoumarol (VKA)

Comedication: bisacodyl suppository 1dd 10 mg p.r.n., ibuprofen 1d 600 mg, metformin 1dd 500 mg, midazolam s.c. 15 mg p.r.n. (in case of lung bleeding), macrogol/electrolytes 1dd 1 sachet, oxycodone IR 6 dd 5 mg p.r.n., pantoprazole 1dd 40 mg, paracetamol 4dd 1000 mg, simvastatin 1dd 40 mg, zolpidem 1dd 10 mg a.n. p.r.n.

Because of a pneumonia amoxicillin 3 dd 500 mg for a week and prednisone 3dd 10 mg for two weeks is started. He receives metoclopramide 3dd 10 mg rectally as needed because of vomiting due to a gastroenteritis. A month later he suffers from a dry cough and ipratropium inhaler 4dd and codeine 3dd 20 mg as needed is started, with limited effect. A week later he is admitted because of hemoptysis and the acenocoumarol is stopped. Back home oxazepam 1dd 10 mg as needed is started in case of anxiety. He gradually deteriorates and dies a month later.