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Systemic Embolism from Mitral Vegetation in Scleroderma

Discussion Salicylates, in general, are contraindicated in patients taking warfarin because of increased risk of bleeding. In high dose, salicylates depress prothrombin formation in the liver and also displace warfarin from protein binding sites", They also have effects on platelets which cause a tendency to bleed even in the presence of a normal INR3-5. These actions, although highly variable5.7 from one patient to another, may be lethal when major bleeding happens to occur. Salicylates, taken in the form of topical ointment, have not been reported to interact adversely with warfarin. The anticoagulation status of our patient had been very stable since her operation. She had taken no additional medications to account for the acute rise in INR apart from methysalicylate ointment. Significant percutaneous absorption of the ointment had occurred as evidenced by a blood salicylate level of 2.5 mmol/l. The acute rise in INR of our patient had, therefore, to be explained by drug interaction between