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NBME 23 Answers

nbme23/Block 2/Question#39 (reveal difficulty score)
A 39-year-old woman with obesity and recently ...
Gemfibrozil ๐Ÿ” / ๐Ÿ“บ / ๐ŸŒณ / ๐Ÿ“–
tags: pharm lipid_disorders fibrates

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 +10  upvote downvote
submitted by โˆ—monkd(21)

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.

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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. +14
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 +4
almondbreeze  Her goal LDL should still be <100, bc she has 3 CHD risk equivalents ( 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. ( +
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 +14
jimdooder  So I ended up going with fibrates because of her age (39). I vaguely remember being taught that statins are really only recommended for patients >40 because the big study that came out about them was in the 40-75 age group. I think this might contribute to the question but I'm not totally sure. +
ytho  This question inspired my screen name +2
cbreland  "Statins are always the answer", "Fat Female 40 Fertile", "Fibrates can cause gallstones". I feel lied to +
brise  I'm not sure if this question is correct. I chose statins according to what an attending told me and UWOLRD 2, I just went back to check and on uworld 2, you only consider giving fibrates if their TG levels are above 1,000. So idk what the nbme is smoking. Or if doctors actually write these questions. +
kavarthapuanusha  Why are we going towards complicated equations?? We have decrease triglycerides and increase hdl therefore fibrates ... If it were decreasing LDL then would go for statins... Only increase hdl mainly go for niacin ..its in uworld and fa +1

 +6  upvote downvote
submitted by โˆ—hayayah(1212)

Femfibrozil is a fibrate, used for lowering TG levels.

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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. +11
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. +9
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. +2

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

 +2  upvote downvote
submitted by dumbo123(2)

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-

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

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peqmd  Agreed got the question wrong too...Here's what I got from Dr. Uptodate DDI. TLDR Increased risk of Rhabdo is worse than increase risk of gallstones. "Concurrent use of clarithromycin or erythromycin together with simvastatin, lovastatin, or atorvastatin was associated with an increased risk of hospitalization for rhabdomyolysis (RR=2.2), acute kidney injury (RR=1.8), or all-cause mortality (RR=1.6), as compared to concurrent use of azithromycin with the statins" +

 +0  upvote downvote
submitted by โˆ—avicenna(12)

honestly just remember Fibrates treat Hypertriglyceridemia and move on. Too many questions too little time. I am a Cool Med Student but I am on Life 9. Research aint big but who the fuck got time. By time we all losing so lil hope trying! Einstein said science is a great thing if one doesn't make a living out of it. I plan on making a living out of medicine and buy my momma a house. I am a real street nikka I came to far to go back home empty handed. My maman hoping her son gon be something one day cant let her down, she sacrificed a lot for us!

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 +0  upvote downvote
submitted by โˆ—avicenna(12)

Hypertriglyceridemia is always treated with Fibrates, even though she is coming for a follow up examination and concetration of TGs is 350 keep giving Gemfibrozil a fibrate.

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 +0  upvote downvote
submitted by โˆ—avicenna(12)

Hypertriglyceridemia is always treated with Fibrates, even though she is coming for a follow up examination and concetration of TGs is 350 keep giving Gemfibrozil a fibrate.

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 -14  upvote downvote
submitted by โˆ—thomasalterman(181)

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.

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redvelvet  this is not that question :) +6

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