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nbme23/Block 2/Question#39

A 39-year-old woman with obesity and recently ...

Gemfibrozil

+4  upvote downvote
submitted by monkd(6),

Am I crazy or did Uworld not have a question that stated Statins are the most effective drug regardless of baseline lipids. This logic threw my off.

adisdiadochokinetic  You are not crazy. I got this question wrong for the same reason but here's why I think NBME was going with fibrates. You can use the Friedewald equation to calculate LDL cholesterol from the values they give. This equation is LDL= Total Cholesterol-HDL Cholesterol-(Triglycerides/5). The Triglycerides/5 term is an estimate for VLDL. If you calculate it in this case you get an LDL of 120 which is firmly normal and thus the patient would ostensibly not benefit from statin therapy. +8
hello36654  omg when the hell am I going to remember this equation? Jesuusssssss, this kind of details makes me want to give up on STEP +2
almondbreeze  Her goal LDL should still be <100, bc she has 3 CHD risk equivalents (https://www.aafp.org/afp/2002/0301/p871.html#afp20020301p871-t3) CHD risk equivalent=the major risk factors that modify LDL goals 1) age(M>45, F>55), 2) smoking status, 3) hypertension(>140/90), 4) ow HDL level (<40), and 5) family history. (https://www.aafp.org/afp/2002/0301/p871.html#sec-4) +
almondbreeze  *low HDL level (refer to table 3 of the article) +
makinallkindzofgainz  These guys are hitting up attending-level cardiovascular risk factor calculations, meanwhile I picked statins because I think I remember that they help the heart +4

The answer is gemfibrozil d/t current gallstones

Her goal LDL should still be <100, bc she has 3 CHD risk equivalents (https://www.aafp.org/afp/2002/0301/p871.html#afp20020301p871-t3) CHD risk equivalent=the major risk factors that modify LDL goals 1) age(M>45, F>55), 2) smoking status, 3) hypertension(>140/90), 4) ow HDL level (<40), and 5) family history. (https://www.aafp.org/afp/2002/0301/p871.html#sec-4)

+/- almondbreeze(27),

+4  upvote downvote
submitted by hayayah(599),

Femfibrozil is a fibrate, used for lowering TG levels.

mousie  I also chose Gemfibrozil too because its the best TG lowering drug listed but I can see where there might be some red flags for this drug in the way they asked the question... 40 year old obese woman with some upper abdominal pain ..... HELLO GALL STONES which is a common adverse outcome of Fibrates. +6
uslme123  Well I didn't wanna give a fat, forty, female, that smokes a fibrate. So a statin, for me, was the best next option. +6
whoissaad  Used same reasoning to choose statins. Fibrates are the main drug of choice for hypertriglyceridemia but given her symptoms, statins made more sense. Why do they do this to us... +
roaaaj  what a tricky question! there are multiple factors should be taken in consideration.. she has triglyceridemia which put her in risk of pancreatitis, and most importantly atherosclerotic disease, and all of that would outweigh the risk of giving her gallstone. +
paulkarr  Yeah I had statins selected initially because "statins are always the answer" but when I saw them stating first line "recently diagnosed with hyper TG" I figured this follow-up was purely to address that. So Fibrate is the best move. +1

100% BS. UpToDate provides the most recent evidence and guidelines that state Fibrate therapy for High TG isn't considered until >500.

+0  upvote downvote
submitted by dumbo123(0),

I think its because she has a hx of peptic ulcer disease (stated in hx) that is currently flaring up (mild epigastric tenderness to deep palpation).

There are drug interactions--- Atorvastatin (choice A), which is a CYP3A4 substrate, shouldn't be used with Clarithromycin/some other antibiotics used to tx peptic ulcers/CYP3A4 inhibitors.

Under warnings and precautions, page 1, FDA- https://www.accessdata.fda.gov/drugsatfda_docs/label/2009/020702s056lbl.pdf https://www.pdr.net/drug-summary/lipitor?druglabelid=2338

(I also got the questions wrong and chose Atorvastatin-- this is just my guess!)

Niacin can cause hyperglycemia, flushing, and gout. NSAID's can treat gout. Aspirin at high concentrations also inhibits renal reabsorption, but it inhibits secretion at low levels. I went with aspirin over acetaminophen b/c although acetaminophen is an analgesic it lacks anti-inflammatory activity.

redvelvet  this is not that question :) +3