Question

Scenario

Mr FG is a 69-year-old retired school teacher who was admitted to the emergencydepartment complaining of severe chest pain after climbing stairs at hisdaughter’s house. In the ambulance he is administered aspirin 300 mg. Onarrival at hospital and subsequent examination and review by the admittingdoctor the following information is obtained.

Previous medical history

Hypertension (10 years). Type 2 diabetes mellitus (recently diagnosed, currentlydiet controlled). The patient is a regular cigarette smoker (>40 per day) anddrinks approximately 10 units of alcohol per week. He has osteoarthritis of theknee.

Family history

Father died following a myocardial infarction at 60 years of age. No maternal

history of cardiovascular disease.

Drug history

Allergies: Trimethoprim. Mr FG has been taking diclofenac MR tablets 75 mg

(twice daily) and nifedipine (Adalat Retard) MR tablets 20 mg (twice daily). Both

were stopped on admission.

Signs and symptoms on examination

▪ Temperature 36.4°C

▪ Blood pressure 160/80 mmHg

▪ Heart rate 75 b/m, regular

▪ Respiratory rate 15 breaths per minute

▪ No basal crackles in the lungs.

▪ An ECG taken immediately on arrival reveals ST elevation of 3 mm in the inferior

▪ leads.

Diagnosis

A preliminary diagnosis of myocardial infarction is made.

Relevant test results

Full blood counts, liver function tests, electrolytes and renal function, CXR,total cholesterol, full blood count and blood glucose were taken at admission.

The following tests taken at admission are reported:

Na+ 134 mmol/L (135–145 mmol/L)

K+ 4.3 mmol/L (3.5–4.0 mmol/L)

Urea 5.2 mmol/L (0–7.5 mmol/L)

Creatinine 81 micromol/L (35–125 micromol/L)

Total cholesterol 5.9 mmol/L (<4 mmol/L)

Blood glucose 4.4 mmol/L (4–10 mmol/L)

Initial treatment

About 45 minutes after the onset of chest pain the patient received the following

treatment in the emergency department:

▪ Heparin 5000 units stat

▪ Reteplase 10 units i.v. bolus followed by a further 10 unit i.v. bolus after 30minutes

▪ Diamorphine 2.5 mg IV stat

▪ Metoclopramide 10 mg stat.

▪ A sliding scale insulin infusion of Actrapid 50 units made up to 50 mL with

sodium chloride 0.9% was initiated and titrated against blood glucose.

The patient is subsequently transferred 2 hours later to the coronary care unit as he is pain-free. As the ward cli

nical pharmacist, you are responsible for dailyreview of drug charts and advice to medical and nursing staff on all aspects ofdrug treatment for patients on the ward.

5. Mr FG experiences a chest infection 4 days post admission and is prescribedamoxicillin 500 mg three times daily and erythromycin 500 mg four times daily.What problems may this cause with this patient’s statin therapy and what advicewould you give in order to avoid this problem occurring? (Drug interaction)

Answer 1

Statins are a class of drugs often prescribed by doctors to help lower cholesterol levels in the blood. By lowering the levels, they help prevent heart attacks and stroke. But rarely statin can cause rhabdomyolysis, it is the muscle damamge and itleads to kidneyfailure and death also.

The combination of the common antibiotic clarithromycin with some statins increases the risk of adverse events, which may require hospital admission for older people.

These antibiotics can increase levels of commonly used statins, or lipid lowering drugs, to dangerous levels a side effect due in part to the fact that both types of drugs interact with the same liver enzyme. The antibiotics actually slow down a liver enzyme so that it can no longer process statins, which then build up in the blood to toxic levels.

Symptoms of toxicity include muscle aches, kidney injury, kidney failure, or worse: Toxicity can even be fatal.

azithromycin may be a safer choice for patients on statin medications,  against infections like pneumonia and is usually given for five days.

No interaction is there with amoxycillin and statin. But inorder to start with any antibiotics patient should tell the doctor about current medication he was own. Some of the food interaction also there with atorvastatin. Grape fruit can increase the blood level of atorvastan and cause liver damage and rabhdomyolysis, ia a serious breakdown of skeletal muscle, cause kidney damage.

If patient develops fever, chills, joint pain or swelling, unusual bleeding or bruising, skin rash, itching, loss of appetite, fatigue, nausea, vomiting, dark colored urine, and/or yellowing of the skin or eyes, as these may be signs and symptoms of liver damage.it need immediate medical attention. There is adverse effect of statins.

Before starting any drug orantibiotics with statin it is necessary to counter check any adverse interaction.if antibiotics is needed they can prefer any alternative for that or can stop temperarely for statin for 5/7days after completion of antibiotics and then restart. There is alo problem with high cholesterol control also.