Aspirin/furosemide

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An event is serious (based on the ICH definition) when the patient outcome is:

• * death

• * life-threatening

• * hospitalisation

• * disability

• * congenital anomaly

• * other medically important event

In a case report, 2 patients [75-year-old man and 77-year-old man] were described, of whom, a 75-year-old man developed thiamine deficiency during treatment with furosemide and a 77-year-old man developed vitamin C deficiency during treatment with aspirin. Additionally, he developed unspecified nutritional deficiency during treatment with furosemide [routes, dosages, durations of treatments to reactions onsets not stated].

Case 1: The 75-year-old man, who had right sided hemiplegia and expressive aphasia from a previous cerebrovascular accident (CVA), complained of a dry cough during the COVID-19 pandemic. He also had a history of coronary artery disease, atrial fibrillation, hypertension and chronic obstructive pulmonary disease. After 6 days of initial symptoms, he tested positive for COVID-19. His symptoms were mild but he had anorexia and poor nutrient intake. After 2 weeks of initial symptoms, he had progressive weakness and functional decline. He could no longer care for himself at home. Subsequently, he was admitted to the hospital. He had symptoms of anorexia, muscle weakness, magnified depression, agitation, irritability and weight loss, which resulted in a malnutrition diagnosis. Before admission to the hospital, his medications included furosemide along with concomitant amlodipine, atorvastatin [atorvastatin calcium], losartan, oxybutynin [oxybutynin chloride], potassium chloride and metoprolol tartrate. Head CT revealed encephalomalacia involving the left thalamus and basal ganglia likely due to previous CVA. For the first 8 days of his hospital days, he had poor oral nutritional intake, despite attempts to increase nutrition with oral nutrition supplements, modifications to meal patterns and frequent encouragement. His neurological findings worsened with waxing and waning delirium, encephalopathy and increasing agitation. A nasogastric feeding tube was placed to provide supplemental nutrition. He was determined to be high risk for refeeding syndrome. On basis of these clinical findings, he was diagnosed with thiamine deficiency. He was recommended thiamine supplementation prior to initiating enteral nutrition. He was treated with IV thiamine for 7 days. Within 72h of feeding tube placement, nutritional needs were met with enteral nutrition. Within 48h of nutrition intervention, he was alert and oriented. His appetite improved, within 4 days of nutrition intervention. Over the following 7 days, he continued to improve with decreasing irritability and resolved delirium. Thereafter, the enteral feeding tube was removed. On hospital day 19, he was discharged. Thiamine deficiency was attributed to furosemide.

Case 2: The 77-year-old man, who had congestive heart failure, chronic kidney disease and type 2 diabetes, was admitted to the hospital for a suspected CVA. He had been receiving aspirin and furosemide along with concomitant atorvastatin [atorvastatin calcium] and insulin aspart. A nutrition-focused physical exam revealed impaired skin integrity, a stage 1 pressure injury on left heel and ecchymosis on left forearm, mottled pale nails, corkscrew hairs on forearms. He was provisionally diagnosed with vitamin C deficiency and treated with vitamin C and high calorie high protein oral nutrition supplements. CVA was ruled out and he was discharged with vitamin C supplementation. During admission, he had no other significant findings, however, he was diagnosed with undetermined encephalopathy. After 8 days, he had a sudden onset of hypoxia. He was admitted for low oxygen saturations, pneumonia and COVID-19 positive status. He was provided supportive care and after 5 days, he was discharged from the hospital. He continued with vitamin C supplements. Unfortunately, over the course of the following month, he developed anorexia which resulted in poor nutritional intake and weight loss. After 60 days of his COVID-19 diagnosis, he was admitted to the hospital with failure to thrive, weight loss, worsened skin integrity, leukocytosis, left lower lung infiltrate and likely aspiration pneumonia and a complicated urinary tract infection. Further, he was diagnosed with vitamin D deficiency and macrocytic anaemia due to folate deficiency related to his severe malnutrition. Head CT revealed tiny focus of hypodensity in right thalamus. He continued to decline throughout admission with worsening mental status. His family declined enteral nutrition and requested hospice care. After 4 days of admission and 10 weeks of COVID-19 diagnosis, he died. Vitamin C deficiency was attributed to aspirin. Unspecified nutritional deficiency was attributed to furosemide.