Drug induced myopathy Edition A team-based mission to combat myopathy

Meijer Pharmacy offers what statin for free? Atorvastatin 10-80 mg

What is the specific statin agent and dose that is still on the market, but not recommended for initiation? X Simvastatin 80 mg Due to the increased risk of myopathy, including rhabdomyolysis, use of the 80-mg dose of ZOCOR should be restricted to patients who have been taking simvastatin 80 mg chronically (e.g., for 12 months or more) without evidence of muscle toxicity. (2.2)

List at least two simvastatin drug-drug interactions - including max dose limitations Interacting Agents Simvastatin Recommendations Strong CYP3A4 inhibitors Contraindicated Verapamil, diltiazem, dronedarone 10 mg/day max Amlodipine, amiodarone, ranolazine 20 mg/day max Strong CYP3A4 inhibitors (e.g., itraconazole, ketoconazole, posaconazole, voriconazole, erythromycin, clarithromycin, telithromycin, HIV protease inhibitors, boceprevir, telaprevir, nefazodone, cobicistat- containing products), gemfibrozil, cyclosporine, danazol

Which statins include grapefruit juice precaution? L A S: Lovastatin, atorvastatin, simvastatin 8 oz of juice or 1 half a grapefruit unlikely to cause an issue – 3A4

Which statin does not require dose adjustment in renal impairment? Atorvastatin At what age is moderate considered adequate for high risk patients? (age 75)

Mary is starting a 10 day course of clarithromycin Mary is starting a 10 day course of clarithromycin. She also takes atorvastatin 40 mg. What should you do? Nothing – there is no drug interaction Counsel her to stop statin while on the antibiotic Call the physician to have her statin switched to Pravastatin At what age is moderate considered adequate for high risk patients? (age 75)

Which two statins are considered “sensitive substrates” because their concentrations can be increased 5x by CYP3A4 inhibitors Simvastatin and lovastatin Strong CYP3A4 inhibitors: Clarithromycin, intraconazole

Which statin has a max dose of 10 mg with select protease inhibitors? Rosuvastatin Limit to 10 mg with lopinavir/ritonavir or atazanavir/ritonavir

Which statin is specifically market as being less likely to cause DDI? Pitavastatin (livalo) https://www.livalorx.com

What OTC product is commonly used to prevent statin induced myopathy? Coenzyme Q10 (ubiquinol) 100-200 mg daily

Which medication used for TG lowering should be avoid with statins? Gemfibrozil

What are two lab levels that may be helpful to rule out other causes of myalgia? TSH Vitamin D

Heart Center of Excellence (bonus points)

The Improve-it provided outcomes data with what medication? Vytorin (ezetimibe and simvastatin)

What new class of lipid-lowering medications was recently FDA approved? PCSK9 Inhibitors Praluent (alirocumab) Repatha (evolocumab) PRALUENT (alirocumab) is a PCSK9 (Proprotein Convertase Subtilisin/Kexin Type 9) inhibitor antibody indicated as adjunct to diet and maximally tolerated statin therapy for the treatment of adults with heterozygous familial hypercholesterolemia or clinical atherosclerotic cardiovascular disease, who require additional lowering of LDL-C. The effect of PRALUENT on cardiovascular morbidity and mortality has not been determined.

The race to prevent myopathy  Decreased ETOH Renally adjust Address drug interactions Evaluate other causes Lower dose Switch statin Use extended regimen Patient education

Rhabdomyolysis risks Myalgia, weakness, dark urine Acute kidney injury Bing drinking trauma elderly Drug interactions Illicit drugs statin fasciotomy