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TM is a 78 YOW with a history of hypertension, hypercholesterolemia and arthritis was admitted for proximal arterial fibrillation.
While in the hospital she was placed on diltiazem drip and eventually, converted to oral diltiazem 240mg. Pt's home medication includes Simvastatin 40mg po daily , hydrochlorothiazide 25mg po daily , Lisinopril 20mg daily and Acetaminophen. Her LDL-C is 100mg /dL.
What would be the most appropriate change to make on her therapy?
A. Change Simvastatin to Lovastatin 20mg po daily
B. Keep Simvastatin at 40mg po daily
C. Increase Simvastatin to 80mg po daily
D. Change Simvastatin 40mg to Atorvastatin 40mg po daily
E. Discontinue Statins.
Answer: D
Explanation:
Explanation
Diltiazem has a major drug interaction with Simvastatin. Diltiazem is a CYP3A4 inhibitor, and since Simvastatin is metabolized by CYP3A4, its level can build up and the risk of myopathy increases. It is recommended to switch to a non-CYP3A inhibitor such as Pitavastatin, Pravastatin, or Rosuvastatin, and if Simvastatin is to be kept on it should not exceed 10 mg/day. The same interaction also exists with lovastatin, and the recommendation is to not exceed a total dose of 20 mg/day po of Lovastatin. Given the current options, the best choice is to change to Atorvstatin 40 mg po daily.

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