A patient on warfarin who also has gastroesophageal reflux disease requires an analgesic after extraction. Which drug should be AVOIDED?

Correct answer: A. Ibuprofen

• A. CORRECT — avoid this. IBUPROFEN carries a double liability here. First, NSAIDs inhibit platelet aggregation and displace warfarin from albumin, potentiating anticoagulation and markedly increasing bleeding risk. Second, NSAIDs are directly ulcerogenic and are contraindicated in a patient with GERD/peptic disease. Combined NSAID + warfarin use significantly increases GI bleeding risk.
• B. Acetaminophen is the analgesic of choice in anticoagulated patients — but keep the dose modest (under 2 g/day) and the duration short, because high-dose sustained acetaminophen can also raise the INR.
• C. Tramadol is acceptable in principle, though it has serotonergic interactions and lowers the seizure threshold.
• D. Opioid combinations are acceptable if needed, though sedation and constipation limit their appeal.

Note: NSAID + anticoagulant + GERD is a three-way problem. Acetaminophen with short-term, low-dose ceiling is the safe choice.