(Medicine (Baltimore))—A 58-year-old man with a history of kidney transplant presented with recurrent syncope; ECG showed tachycardia and anterolateral myocardial ischemia. Admission labs: Hgb 9.9 g/dL; creatinine 2.1 mg/dL; CrCl 40.48 mL/min; troponin I 1.2 ng/mL; CK-MB 120 ng/mL; WBC and BNP within normal range. Dx: ACS. Coronary angiography revealed total occlusion in proximal left anterior descending (LAD) and intimal flap in proximal left circumflex (LCX), with collateral vessels from LCX connecting to LAD distal to the occlusion. PCI was performed and a stent placed in proximal LCX, covering the ruptured plaque, with an unsuccessful attempt to open the occlusion in LAD. Repeat angiogram showed no signs of vessel dissection, perforation, or thrombus formation. Low-dose aspirin, ticagrelor, atorvastatin, and olmesartan were started for secondary prevention. Gum bleeding and bloody stool appeared 8 days later, accompanied by a sudden drop in blood pressure. Olmesartan was d/c and IV pantoprazole given to stop life-threatening GI bleeding.

Preadmission meds: cyclosporine, mycophenolate mofetil. Meds started during admission: atorvastatin, low-dose aspirin, olmesartan, ticagrelor.

Which drug combo could have caused the GI bleed?
cyclosporine and ticagrelor
aspirin and mycophenolate
cyclosporine and olmesartan
atorvastatin and ticagrelor
You are correct. Ticagrelor reduces platelet activation and aggregation, and significant bleeding may occur with use of this drug. Cyclosporine, a moderate CYP3A4 inhibitor and strong P-glycoprotein (P-gp) inhibitor, inhibits the metabolism and P-gp–mediated transport of ticagrelor, leading to increased systemic exposure and risk of adverse effects; therefore, coadministration with cyclosporine should be used with caution. Furthermore, ticagrelor, a weak CYP3A4 inhibitor and weak P-gp inhibitor, inhibits the metabolism and P-gp–mediated transport of cyclosporine, leading to increased systemic exposure.

No significant interactions are known or found for aspirin and mycophenolate, though GI perforation and bleeding have been reported with aspirin alone.

Though bleeding isn’t associated with cyclosporine and olmesartan, the combined use of cyclosporine and olmesartan may increase the additive risk of hyperkalemia and nephrotoxicity, warranting monitoring of potassium and renal function.

Though bleeding isn’t associated with artorvastatin and ticagrelor, ticagrelor (weak P-gp inhibitor) may increase atorvastatin levels via inhibition of P-gp–mediated transport of atorvastatin, leading to an increased risk of myopathy, rhabdomyolysis, and other adverse effects.

Source article: Zhang C, Shen L, Cui M, Liu X, Gu Z. Ticagrelor-induced life-threatening bleeding via the cyclosporine-mediated drug interaction: A case report. Medicine (Baltimore). 2017;96(37):e8065. doi: 10.1097/MD.0000000000008065.

More info is available in the free, full-text Medicine (Baltimore) article PDF at PubMed Central.
What percentage of adults receive a type 1 diabetes diagnosis after the age of 30?
You are correct. Data on 947 adults with type 1 diabetes showed that 37% did not receive a diagnosis until after the age of 30, and delayed diagnoses were most common among men and diverse racial groups, according to findings published in the journal Annals of Internal Medicine.

Fang M, et al. (2023, September 26). Ann Intern Med. PubMed® abstract
Can you identify this pill?
You are correct. Levofloxacin is a fluoroquinolone antibiotic used to treat pneumonia, prostatitis, bacterial skin infections, and UTI, among other infections. It's also used to treat adults and children exposed to anthrax or plague.

As a reminder, you can use the Pill ID feature to identify a pill based on its imprint code or physical characteristics, including shape, color, and scoring. Find Pill ID in the epocrates app or on epocrates web.
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By rray, 26 September, 2023