A 64-year-old lady with hypercholesterolaemia, hypertriglyceridemia, hypertension, chronic kidney disease and a history of stroke attends for review. She is complaining of generalised muscle pain. Her usual medications include aspirin, simvastatin, gemfibrozil, diltiazem and atenolol.

a) What is the mechanism of action of statins? (2 marks)

b) Her low-density lipoprotein cholesterol (“LDL-C”) was 3.0 mmol/L and remains suboptimal. Name TWO statins that are of higher potency than simvastatin. (2 marks)

c) Her creatinine kinase was elevated two times above normal limit. Which of her concomitant medications may interact with simvastatin and increase the risk of statin-associated myopathy? Explain the mechanisms of interaction. (4 marks)

d) Apart from drug-drug interactions,  what additional risk factors may increase the risk of statin-associated myopathy? (6 marks)

e. Which class of drug does gemfibrozil belong to? Name one other lipid-lowering drug within the same class.  (2 marks)

f) In patients who are statin-intolerant,  describe  TWO  other classes of drugs that may be used for LDL-C lowering. Explain their mechanism of action. (4 marks)