Pharmacology · patient case with 1 question
Bleeding risk in a patient with HIV, hepatitis C and alcohol dependence
Patient: Male, 52 years old
Chief Complaint: “Two of my teeth need to come out.”
Background: HIV on antiretroviral therapy with an undetectable viral load. Chronic hepatitis C with early cirrhosis. Ongoing alcohol use. Treated for depression with CITALOPRAM. No anticoagulants.
Vital Signs: BP 122/76 mmHg · HR 84 bpm · CD4 520 cells/µL · platelets 92,000/µL · INR 1.4
Findings: Two non-restorable teeth requiring extraction. Generalized periodontitis. No acute infection.
Question 1
Which of his medications independently increases his bleeding risk at extraction?
Show answer and explanation
Correct answer: D. Citalopram
- A. Something clearly does — the question is which.
- B. Antiretroviral drugs are not associated with impaired haemostasis. Some protease inhibitors have been linked to spontaneous bleeding in haemophiliacs specifically, but that is not a general effect.
- C. Acetaminophen does NOT inhibit platelet function, which is exactly why it is the analgesic of choice when bleeding risk matters — though the dose ceiling must be reduced in cirrhosis and continued alcohol use.
- D. CORRECT. CITALOPRAM, like all SSRIs, impairs platelet function. Platelets do not synthesise serotonin — they take it up from plasma through the same transporter the drug blocks, and serotonin released from platelet granules is a key amplifier of aggregation. Blocking uptake DEPLETES the platelet serotonin store, so aggregation is impaired. The effect is modest alone but compounds substantially here, on top of thrombocytopenia and a prolonged INR from cirrhosis, and it compounds again with any NSAID.
Note: Three separate contributors are stacked in this patient: thrombocytopenia from cirrhosis and hypersplenism, reduced synthesis of clotting factors reflected in the INR, and SSRI-induced platelet dysfunction. Plan for it: atraumatic technique, local haemostatic measures in every socket, sutures, tranexamic acid mouthwash, and NO NSAIDs. The CD4 of 520 with an undetectable viral load means his immune status is not the concern here.