What should I do for a 32-year-old with unexplained bruising under the left arm, who recently started naproxen (Nonsteroidal Anti-Inflammatory Drug), omeprazole (Proton Pump Inhibitor), and diazepam (Benzodiazepine) for back pain?

Management of Unexplained Bruising in a Patient on Naproxen, Omeprazole, and Diazepam

Naproxen is the most likely cause of the unexplained bruising under the left arm and should be discontinued immediately while investigating for potential bleeding disorders.

Initial Assessment and Management

Immediate Steps:

• Discontinue naproxen immediately due to its antiplatelet effects and increased bleeding risk 1
• Continue omeprazole as it provides gastroprotection while on NSAIDs 2
• Consider alternative pain management options for back pain

Required Blood Tests:

1. Complete Blood Count (CBC) - to assess for anemia, platelet count, and other hematological abnormalities 1
2. Coagulation profile - PT/INR, aPTT to evaluate bleeding risk
3. Liver function tests - to assess for hepatotoxicity which can be caused by NSAIDs 1
4. Renal function tests - NSAIDs can impair renal function
5. Inflammatory markers - ESR, CRP to evaluate for underlying inflammatory conditions

Medication Considerations

Naproxen Concerns:

• NSAIDs like naproxen inhibit platelet aggregation and prolong bleeding time 1
• This effect is reversible but can cause significant bruising and bleeding risk 1
• Patients with altered platelet function or those receiving anticoagulants should be carefully monitored when on NSAIDs 1

Drug Interactions:

• The combination of naproxen, omeprazole, and diazepam may increase bleeding risk
• Benzodiazepines like diazepam have not been shown to improve outcomes when combined with NSAIDs for back pain 3
• A study showed that adding diazepam to naproxen did not improve functional outcomes or pain compared to naproxen alone 3

Alternative Pain Management

Evidence-Based Options:

1. Acetaminophen - Consider as first-line alternative with fewer bleeding risks 2
2. Physical therapy - Non-pharmacological approach for back pain
3. Topical analgesics - For localized back pain without systemic effects

If NSAIDs Must Be Continued:

• Use the lowest effective dose for the shortest duration 2, 4
• Continue omeprazole for gastroprotection 2
• Monitor for signs of GI bleeding or additional bruising 2

Follow-up Plan

Short-term Follow-up:

• Review blood test results within 48-72 hours
• Reassess bruising area for progression or resolution
• Evaluate effectiveness of alternative pain management

Red Flags Requiring Immediate Attention:

• Expansion of bruising area
• New bruises in other locations
• Signs of GI bleeding (black stools, hematemesis)
• Severe abdominal pain
• Dizziness or syncope

Special Considerations

Medication-Specific Risks:

• Naproxen carries both GI and bleeding risks that are dose-dependent 2
• Patients over 60 years have increased risk of NSAID complications, though this patient is younger 2
• Omeprazole is appropriate to continue as it reduces gastrointestinal adverse effects induced by NSAIDs 2

Evidence Summary:

• Studies show that NSAIDs like naproxen are effective for short-term pain relief in back pain but carry bleeding risks 2
• Adding benzodiazepines like diazepam to naproxen has not shown improved outcomes for back pain 3, 5
• Patients with unexplained bruising while on NSAIDs should be monitored for more serious bleeding complications 1

By discontinuing naproxen and conducting appropriate blood tests, you can determine if there is an underlying bleeding disorder while protecting the patient from potential complications.