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Act as a clinical pharmacologist. A fictional 82-year-old woman (eGFR 28) is taking apixaban 5mg BD, digoxin 125mcg OD, furosemide 40mg OD, amitriptyline 25mg ON, ibuprofen 400mg TDS, metformin 1g BD, citalopram 20mg OD. Active problems: AF, CKD stage 4, osteoarthritis, depression, recurrent falls. (1) Flag every significant drug-drug and drug-disease interaction with its severity. (2) Tabulate renally-cleared drugs needing a dose change and the adjusted dose. (3) Apply STOPP/START for deprescribing candidates and missing indicated therapy. (4) Give a prioritized, week-by-week deprescribing and monitoring plan. Show your reasoning and name the rule behind each recommendation.

Synthetic case with a described image. Run it as-is, or attach a real de-identified image following your local safety policy.