diltiazem + simvastatin

[ronkoshy]

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[crazybob]

and by the way, same situation for amiodarone and simvastatin (or ANY hmg-co A reducatse inhibitor).. correct?

That's what Lexi-Comp says.

It also says:

Consider Using a non-interacting HMG-CoA reductase inhibitor in patients receiving amiodarone

which seem to be pitavastatin and pravastatin, according to the exceptions on the HMG-CoA Reductase Inhibitors Interacting Members.

It goes on to say:

Dose reductions of the HMG-CoA Reductase Inhibitor may be necessary with concurrent amiodarone therapy (eg maximal dose of simvastatin = 20 mg/day).

 

[Old Timer]

If the dose is at or below the max suggested, I counsel on what to look for, pain, muscle weakness, change in the color of the urine, etc....

If it's over the max, I call the doctor & document the response. Sometimes they change and sometimes they have not clue about what I am saying.....

 

[J ROD]

If the dose is at or below the max suggested, I counsel on what to look for, pain, muscle weakness, change in the color of the urine, etc....

If it's over the max, I call the doctor & document the response. Sometimes they change and sometimes they have not clue about what I am saying.....

this......I would say that patient is probably okay since they were monitored in the hospital being on both.

 

[PumpkinSmasher]

If the dose is at or below the max suggested, I counsel on what to look for, pain, muscle weakness, change in the color of the urine, etc....

If it's over the max, I call the doctor & document the response. Sometimes they change and sometimes they have not clue about what I am saying.....

Curious, what is your usual protocol when it comes to a 7-10 day bactrim courses for warfarin patients. So far in my intern career, I always call and document and see if they want to try another ABX or at least make sure they will see the patient soon for monitoring.

 

[WVUPharm2007]

Curious, what is your usual protocol when it comes to a 7-10 day bactrim courses for warfarin patients. So far in my intern career, I always call and document and see if they want to try another ABX or at least make sure they will see the patient soon for monitoring.

It's just a week. Any changes are will be minor and insignificant. I suppose it depends on how ridiculously anal you want to be.

 

[J ROD]

usually counsel the patient on it and see when they are going back to the doctor....

Since it is for a short period of time, I dont usually call on it unless the patient appears like they might need some intervention, ie, fall risk.

 

[Old Timer]

Curious, what is your usual protocol when it comes to a 7-10 day bactrim courses for warfarin patients. So far in my intern career, I always call and document and see if they want to try another ABX or at least make sure they will see the patient soon for monitoring.

If it's the same doctor ordering the Bactrim & Coumadin, I might not say anything. If it's a different doctor or an ER doc, I ask when the next INR is and based on their answer, I may suggest they contact the doctor monitoring the warfafin to see if they want to move up the INR.

 

[Ackj]

It's a common interaction, most docs are aware of it and are fine as long as you're using 40mg rather than 80... sometimes they're on 80 and you have to take them down to 40. Similar situation with fibrates. Some people switch to pravastatin, might want to consider that, especially since the patient already has some muscle pain.

 

[Pharmer Tony]

It's just a week. Any changes are will be minor and insignificant. I suppose it depends on how ridiculously anal you want to be.

The Bactrim/Warfarin interaction is mostly from Bactrim displacing warfarin from plasma proteins-- this has immediate effects.

I work at a hospital and occasionally at the warfarin clinic. I see INRs go from 2.5--> 5 or 6 in 2-4 day frequently because of Bactrim. As with all things warfarin, there's variability, however this has been heavily studied and documented (for a drug interaction.) I'd make an intervention if I ever saw that combination.

To the OP: I would have let the diltiazem/zocor go through since the simvastatin was 40mg; if it had been 80 I would have recommended cutting the dose or change the statin to pravachol.

 

[WVUPharm2007]

The Bactrim/Warfarin interaction is mostly from Bactrim displacing warfarin from plasma proteins-- this has immediate effects.

I work at a hospital and occasionally at the warfarin clinic. I see INRs go from 2.5--> 5 or 6 in 2-4 day frequently because of Bactrim. As with all things warfarin, there's variability, however this has been heavily studied and documented (for a drug interaction.) I'd make an intervention if I ever saw that combination.

To the OP: I would have let the diltiazem/zocor go through since the simvastatin was 40mg; if it had been 80 I would have recommended cutting the dose or change the statin to pravachol.

Well...all of my experience is drawn from being a hospital typing monkey...where most interactions we can conveniently ignore...but if I'm working at a retail pharmacy, I agree, I'd call...because in retail pharmacy, being anal is a necessity...

On the other hand, there is this...of course that's inpatients...who are already worse off...which actually slightly amazes me because they prolly should be getting INRs all the damn time...

...and I like how people are now registering to specifically tell me how stupid I am. SDN owes me some money or something.

 

[Rebel78]

Pravastatin or lovastatin should work.

 

[Pharmavixen]

I did find this case report that purports to be the 1st recorded instance of rhabdo resulting from dilt + sim. The risk is low, however; I looked at a systematic review a couple of years ago that found rhabdo from statins wasn't statistically sig when you eliminated studies that included cerivastatin.

I'm not sure about the whole muscle aches from statins thing; lots of people suffer from muscle aches and don't give it a 2nd thought, but if they're on a statin, they blame it. So there's all these anecdotal reports of statins causing muscle aches. I dunno...rhabdo causes weakness rather than pain as the signature muscular symptom.

That said, I'd change to another statin that's not affected by 3A4.

 

[All4MyDaughter]

Well...all of my experience is drawn from being a hospital typing monkey...where most interactions we can conveniently ignore...but if I'm working at a retail pharmacy, I agree, I'd call...because in retail pharmacy, being anal is a necessity...

On the other hand, there is this...of course that's inpatients...who are already worse off...which actually slightly amazes me because they prolly should be getting INRs all the damn time...

...and I like how people are now registering to specifically tell me how stupid I am. SDN owes me some money or something.

My facility considers Bactrim/warfarin a major clinically significant drug interaction and we do modify the patient's warfarin therapy while they are being treated with Bactrim. I don't have the guidelines in front of me b/c I'm at home.

 

[WVUPharm2007]

Being that I walked in straight out of school and noted like 10 things they were doing wrong....perhaps I should just erase all memories of ever working in that hospital. A place where giving half of the patients buprenex and allowing 1 pharmacist to care for a census of 175 is normal...

 

[J ROD]

The Bactrim/Warfarin interaction is mostly from Bactrim displacing warfarin from plasma proteins-- this has immediate effects.

I work at a hospital and occasionally at the warfarin clinic. I see INRs go from 2.5--> 5 or 6 in 2-4 day frequently because of Bactrim. As with all things warfarin, there's variability, however this has been heavily studied and documented (for a drug interaction.) I'd make an intervention if I ever saw that combination.

looks like I need to reconsider.....

 

[Pharmavixen]

A place where giving half of the patients buprenex and allowing 1 pharmacist to care for a census of 175 is normal...

Do they also dispense lots of methadone? This sounds sort of like the job I had at the pharmacy next door to the drug addiction treatment clinic: most of the pts < 50 y.o., lots of methadone, buprenorphine, antidepressants, NSAIDS. One pharmacist and 2 techs would fill 400 scripts/shift sort of thing.

 

[GreyFox2002]

Pravastatin or lovastatin should work.

Lovastatin is metabolized via CYP3A4 so I feel that it wouldn't be the best choice. The problem with pravastatin is that it has very little evidence of effectiveness above 40 mg. If you need significant LDL lowering, go with rosuvastatin.