A 78-year-old female, 55 kg, with a history of atrial fibrillation, is admitted to the emergency department with prolonged bleeding from a minor cut. Her current medications include dabigatran 150 mg PO BID, metoprolol 50 mg PO daily, and atorvastatin 40 mg PO nightly. Her creatinine clearance is estimated at 35 mL/min. Which of her current medications is most concerning for contributing to her bleeding event, given her renal function?

Question: A 78-year-old female, 55 kg, with a history of atrial fibrillation, is admitted to the emergency department with prolonged bleeding from a minor cut. Her current medications include dabigatran 150 mg PO BID, metoprolol 50 mg PO daily, and atorvastatin 40 mg PO nightly. Her creatinine clearance is estimated at 35 mL/min. Which of her current medications is most concerning for contributing to her bleeding event, given her renal function?

Answer options:

• Metoprolol
• Atorvastatin ✅ Dabigatran
• All of the above

Correct answer: Dabigatran

Explanation: Dabigatran is primarily renally cleared, and its dose should be adjusted in patients with renal impairment. For CrCl 30-50 mL/min, the recommended dose is 110 mg BID, suggesting the 150 mg BID dose may be supra-therapeutic for this patient, increasing bleeding risk.