Simvastatin 4- Nicotinic acid

Drugs that may affect repaglinide include CYP 450 inhibitors (eg, clarithromycin, erythromycin, ketoconazole, miconazole), CYP 450 inducers (eg, barbiturates, carbamazepine, rifampin), beta blockers, calcium channel blockers, chloramphenicol, corticosteroids, coumarins, estrogens, gemfibrozil, isoniazid, itraconazole, levonorgestrel and ethinyl estradiol, MAOIs, nicotinic acid, NSAIDs, oral contraceptives, phenothiazines, phenytoin, probenecid, salicylates, simvastatin, sulfonamides, sympathomimetics, thiazides and other diuretics, and thyroid products. 

Simvastatin is also used in combination with nicotinic acid. It is found to be the most useful drug combination for the treatment of dyslipidemias associated with coronary artery disease. It is particularly effective in normalizing the lipid profiles of patients with familial combined dyslipidemia. 

Abbreviations AM, amlodipine AT, atorvastatin DS, diclofenac sodium EZ, ezetimibe FB, fenofibrate HAT, hydroxy atorvastatin IS, internal standard o-HAT, ortfio-hydroxy atorvastatin p-HAT, para-hydroxy atorvastatin HPLC-ESI-MS, high-performance liquid chromatography with electrospray tandem mass spectrometry LV, lovastatin NA, nicotinic acid NB, novobiocin FV, pravastatin RV, rosuastatin SV, simvastatin RT, roxethromycin UPLC, ultra performance liquid chromatography. 

Clinically important, potentially hazardous interactions with atorvastatin, bexarotene, cyclosporine, dicumarol, ezetimibe, fluvastatin, interferon alfa, lovastatin, nicotinic acid, pioglitazone, pravastatin, repaglinide, rosuvastatin, roxithromycin, simvastatin, statins, warfarin... 

Drugs that can cause myopathy or rhabdomyolysis, including fibric acid derivatives and nicotinic acid, increase the risk of developing these conditions if given in association with simvastatin. 

Although these cases are isolated, some caution is certainly warranted. The US manufacturers of lovastatin recommend a maximum dose of 20 mg in patients taking nicotinic acid in doses of 1 g or more daily. Similarly the UK manufacturers of simvastatin recommend a maximum dose of 10 mg in patients taking nicotinic acid in doses of 1 g or more daily." To be on the safe side, if the decision is made to use nicotinic acid with any statin the outcome should be very well monitored. Patients should be told to report otherwise unexplained muscle pain, tenderness or weakness or dark coloured urine). See also muscle toxicity , (p.l086), for further guidance on monitoring, and risk factors for muscle toxieity. 

Carboxyl group clofibrate, ciprofibrate, etodolac, fenoprofen, ibuprofen, ketoprofen, naproxen (racemic > 5), valproic acid and formation of simvastatin and atorvastatin lactones via an intermediate acyl glucuronide Tertiary amines amitriptyline, chlorpheniramine, chlorpromazine, clozapine, cyproheptadine, diphenylamine, doxepin, imipramine, ketotifen, loxapine, promethazine, tripellenamine, trifluoperazine Aromatic heterocyclic amines croconazole, lamotrigine, nicotine (30X velocity than UGT1A3), 1-phenylimidazole, posaconazole, retigabine Primary and secondary amines ... 

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