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An 80-year-old woman with a long-term history of rheumatoid arthritis and heart failure was admitted to a nursing home following knee replacement surgery. She was receiving high-dose methotrexate 20 mg/day and naproxen sodium 550mg twice daily [routes and treatment durations not stated]; her other medications included digoxin, metoprolol, lisinopril, paracetamol [acetaminophen] and furosemide. Upon admission, she was oedematous and had gained 3lb, perhaps secondary to naproxen. Temporary disuresis was required. Her renal function was impaired (creatinine clearance 20 mL/min), putting her at increased risk of methotrexate toxicity. She subsequently died from a massive bleeding event [times to onset not stated].Author Comment"Concomitant administration of NSAIDs [nonsteroidal anti-inflammatory drugs] with high-dose methotrexate therapy has been reported to elevate and prolong serum concentrations of methotrexate, resulting in death from severe hematologic and gastrointestinal toxicity."