Clarithromycin inhibits CYP3A4 thus markedly raises the conc of statins extensively. Contraindicated. Avoid concomitant use.

=> increased risk of rhabdomyolysis

2. Clarithromycin + diltiazem

(i) Clarithromycin inhibits CYP3A4, which CCB (diltiazem) is at least in part metabolized.

(ii) Clarithromycin is also a P-glycoprotein inhibitor. This might contribute to PK interaction by reducing elimination of CCB, or increase macrolide absorption.

=> increased conc and adverse effects, which are hypotension and QT prolongation.

3. Simvastatin + diltiazem

Diltiazem moderately inhibits CYP3A4, which metabolizes Simvastatin.

=> concurrent use increases level of statin, increasing the risk of myopathy. Monitor since the pt has been taking Simvastatin and diltiazem together.

All are PK (metabolism) interaction.

- pravastatin not metabolised by CYP3A4

- Dosage (10-40 mg OD at night)

- or fluvastatin(20-40 mg OD at night)

2. Change clarithromycin to azithromycin

- due to interaction with simvastatin and diltiazem

- Dosage 500mg OD x 3/7

Aspirin - NSAID and anti platelet. Dosage is correct. Best taken after meal.

Simvastatin - primary hypercholesterolaemia. Dosage is correct.

Clarithromycin - treat chest infection. Dosage is correct.

• The cessation of smoking will reduce the risk of cardiovascular disease.
  
• Nicotine increase the blood pressure and heart rate.
  
• Cigarette smoke induces arterial stiffness.
  
• Avoid increasing the risk of secondary cardiovascular complications and enhance the progression of renal insufficieny.