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Case 5: Antiretrovirals and Statins

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D The patient's clinical presentation is best explained by drug-induced rhabdomyolysis and acute renal failure caused by elevated blood levels of simvastatin. The increased simvastatin levels resulted from co-administration of simvastatin with lopinavir-ritonavir.

This answer is correct. Ritonavir is a known potent inhibitor of cytochrome P450 3A4 enzymes and many of the statins are metabolized via these enzymes. Ritonavir can increase simvastatin plasma concentrations by 3000%. Simvastatin is contraindicated for use with all protease inhibitors. In this case, simvastatin should immediately be discontinued. Other statins could be used in its place if necessary. To ameliorate the lipid abnormalities, it may also be beneficial to modify the patient's antiretroviral therapy regimen and use a different protease inhibitor combination.


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