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

2. Meijer Pharmacy offers what statin for free?
Atorvastatin mg

3. 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)

4. 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

5. 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

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

7. 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)

8. 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

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

10. Which statin is specifically market as being less likely to cause DDI?
Pitavastatin (livalo)

11. What OTC product is commonly used to prevent statin induced myopathy?
Coenzyme Q10 (ubiquinol)
mg daily

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

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

14. Heart Center of Excellence (bonus points)

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

16. 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.

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

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