Diltiazem has a major drug interaction with Simvastatin. Diltiazem is a CYP3A4 inhibitor, and since Simvastatin is metabolized by CYP3A4, its level can build up and the risk of myopathy increases. It is recommended to switch to a non-CYP3A inhibitor such as Pitavastatin, Pravastatin, or Rosuvastatin, and if Simvastatin is to be kept on it should not exceed 10 mg/day. The same interaction also exists with lovastatin, and the recommendation is to not exceed a total dose of 20 mg/day po of Lovastatin. Given the current options, the best choice is to change to Atorvstatin 40 mg po daily.
Reference:
http://www.fda.gov/Drugs/DrugSafety/ucm256581.htm
http://circ.ahajournals.org/content/129/25_suppl_2/S1

Explanation
(A) Sulfonylureas, (C) DPP4 Inhibitors, (D) Glucagon-like peptide-1 receptor agonists Sulfonylureas work in beta cells in the pancreas that are still functioning to enhance insulin secretion. Alpha-Glucosidase Inhibitors stop -glucosidase enzymes in the small intestine and delay digestion and absorption of starch and disaccharides which lowers the levels of glucose after meals. DPP4 blocks the degradation ofGLP-1, GIP, and a variety of other peptides, including brain natriuretic peptide. Glucagon-like peptide-1 receptor agonists work in various organs of the body. Glucagon-like peptide-1 receptor agonists enhance glucose homeostasis through: (i) stimulation of insulin secretion; (ii) inhibition of glucagon secretion; (iii) direct and indirect suppression of endogenous glucose production; (iv) suppression of appetite; (v) enhanced insulin sensitivity secondary to weight loss; (vi) delayed gastric emptying, resulting in decreased postprandial hyperglycaemia.Thiazolidinediones are the only true insulin-sensitising agents, exerting their effects in skeletaland cardiac muscle, liver,and adipose tissue. It ameliorates insulin resistance, decreases visceral fat.Biguanides work in liver, muscle, adipose tissue via activation of AMP-activated protein kinase (AMPK) reduce hepatic glucose production. SGLT2 inhibitors work in the kidneys to inhibit sodium-glucose transport proteins to reabsorb glucose into the blood from muscle cells; overall this helps to improve insulin release from the beta cells of the pancreas.

Explanation
KCl: Osmoles = number of particles in solution Convert 40meq to weight in g: 40meq * 1equiv/1000 mEq *
74.5g/1 equiv = 2.98g of KCL. Calculate mOsm/L: 2.98g/L * 1mol/74.5g * 2Osm/1 mol * 1000mOsm/1 Osm
= 80mOsm/L. NaCl: 0.9g/100ml * 1mol/58.5 g * 2 Osm/1mol * 1000 mOsm/ 1Osm * 1000ml/1L = 308 mOsm/L 80 mOsm/L + 308 mOsm/L = 388 mOsm/L

Explanation
Incidence rate = New reported cases / summed person-years of observation (avg population during time interval). Prevalence = Cases in a population in a given time period / total population at that time Mortality rate
= deaths during specified time interval / population size at risk for death.

Explanation
Sucralfate is a drug used to treat active duodenal ulcers and may also be used to treat GERD or stress ulcers.