COW Week 17

61 yo patient with diabetes (HbA1c 7.2 on metformin) has been on Lipitor 80mg for over one year. His LDL is 146, HDL is 44, Tg are 118. How should you address his lipid profile?

a. add Zetia 10mg/day

b. change Lipitor to Crestor

c. add Niacin

d. add another statin

The first thing one should do is ensure the patient is taking the medication correctly and adhering to a strict diet and exercise regiment. The next step would be to try a more potent statin (Crestor).

Zetia has been show to decrease LDL by 14-17% when combined with a statin, however there is no evidence that addition of Zetia has any effect on mortality or cardiovascular outcomes.

The ENHANCE trial randomized patients to simvastatin 80mg with or without ezetimbide 10mg daily. Combination therapy provided a significant LDL decrease and HDL increase. However, there was no difference in primary outcome of carotid intima-media thickness or cardiovascular events.  The ARBITER 6-HALTs trial took patients with CHD or CHD equivalents who were already on statins and randomized them to niacin or ezetimibide. Addition of Niacin had better outcomes then addition of ezetimibide. We already know from the AIM-HIGH trial that niacin really provides no benefit in patients already on a statin. Thus, all this data seems to suggest that the addition of ezetimibe does not provide clinical benefit. Additionally, ezetimibe has some potential concerning side effects including a possible cancer link that was noted the SEAS trial.

In the absence of an indication other than prevention of CHD, do not treat patients with another lipid-lowering medication in combination with a statin even if the LDL-C is not at goal. There is a theory that the actual statin itself is more important than the LDL goal. Some advocate only adding on a second lipid lowering agent if the LDL is still greater then 160. 

The ATP 4 committee is actually discussing this issue right now and we asked our expert for insider information. Unfortunately, it is classified, so all we can advise is that it is a grade E recommendation (ie: expert opinion but little or no data to support it) to consider adding a second class of lipid lowering drugs in select patients. 

Statins are the only lipid lowering class of drugs to demonstrate clear improvements in overall mortality in primary and secondary prevention. It is reasonable to try a different statin as you may see better results and Crestor is more potent then lipitor.

COW week 16

40 yo F admitted for CAP, Has PCN allergy, no other PMHx. Febrile to 102.3, HR 105. BP 122/67. O2 is 96% on 2LNC. Patient is placed on levofloxacin. In addition to DVT Px, what other preventive measures should be considered?

Pepcid 20 mg po BID
Lactobacillus 1 cap Daily- Correct Answer
Protonix 40 mg daily
Pneumovax




Rationale:

This patient is healthy and has become ill with community acquired pneumonia.  Based on the question stub, there is no prior history of pneumonia or other recurrent infections. There is no data the pneumovax in indicated in patients presenting with CAP without other indications for Pneumovax

From the CDC  website- Adult indications 23-Valent Pneumococcal Polysaccharide Vaccine

• All adults 65 years of age and older.
• Anyone 2 through 64 years of age who has a long-term health problem such as: heart disease, lung disease, sickle cell disease, diabetes, alcoholism, cirrhosis, leaks of cerebrospinal fluid or cochlear implant.
• Anyone 2 through 64 years of age who has a disease or condition that lowers the body’s resistance to infection, such as: Hodgkin’s disease; lymphoma or leukemia; kidney failure; multiple myeloma; nephrotic syndrome; HIV infection or AIDS; damaged spleen, or no spleen; organ transplant.
• Anyone 2 through 64 years of age who is taking a drug or treatment that lowers the body’s resistance to infection, such as: long-term steroids, certain cancer drugs, radiation therapy.
• Any adult 19 through 64 years of age who is a smoker or has asthma.
• Residents of nursing homes or long-term care facilities.

Given that this patient has 1 episode of CAP, she does not meet criteria for any of the above so should not have the testing.  Of note, the patient only has a 25% chance of having her CAP from Penumococcus to begin with:

Percentage of pathogens in CAP in inpatients NOT admitted to ICU:

S. pneumoniae 25% Respiratory viruses10% M. pneumoniae 6% H. influenzae 5% C. pneumoniae  3% Legionella species 3% Unknown 37%
	With regard to GI prophylaxis with PPI or H2 Blocker- the indications for Stess Ucler Prophylaxis are as follows: Coagulopathy (plts<50 inr="inr">1.5, ptt> 2x over control) Mechanical Ventilation > 48 hours Traumtic Brain or Spinal cord injury Severe Burns  2 or more of the following: Sepsis, ICU x7+days, GI bleed without a source >6 days, or equivalent prednisone dose 50 mg/day or more The patient meets none of these critera and has no hx of GERD or PUD so does not require acid suppression.  The addition of a PPI is associated with increased risk of C. Diff colitis The patient is on antibitiotics for her infection, and fluroquinolones are associated with risk of C. Diff Colitis.  A recent meta-analysis published online ahead of print in the Annals of Internal Medicine (www.annals.org) found that in 13 trials, patient on antibiotics who were given probiotics had a reduced the incidence of C. Diff associated diarrhea by 66% (pooled relative risk, 0.34 [95% CI, 0.24 to 0.49]).  Though there was variability of the type and dose of probiotic, the effect size was large.   Thus in this patient, probiotics (in this case lactobacillus caps) may be considered to reduced her risk of complications from her antibiotic therapy.