Prescribing Wordle Archive
Every past puzzle — with the answer revealed and a clinical pearl to reinforce your pharmacology knowledge.
14 puzzles in this series
Atorvastatin
HMG-CoA reductase inhibitor
Male, 58 yo. Admitted with NSTEMI, PCI performed on LAD. LDL 3.8 mmol/L, TG normal, no prior statin therapy. Cardiologist targets LDL <1.4 m…
Mechanism: ~51% LDL reduction at 80 mg — high-intensity; second most potent statin after rosuvastatin; most prescribed globally; inhibits hepatic HMG-CoA reductase
Rosuvastatin
HMG-CoA reductase inhibitor
Female, 62 yo. No prior CVD. LDL 2.4 mmol/L (apparently normal), but hsCRP persistently 4.2 mg/L. Non-smoker, no diabetes. Cardiologist init…
Evidence: JUPITER trial: 44% RRR in CV events in patients with normal LDL but elevated hsCRP — reshaped treatment thresholds
Simvastatin
HMG-CoA reductase inhibitor
Male, 71 yo. Stable angina on amlodipine 10 mg and diltiazem. Longstanding dyslipidaemia on a statin. GP increases the dose to the historica…
FDA restriction: 80 mg dose restricted (2011) due to excess myopathy/rhabdomyolysis — 40 mg is the current approved maximum
Pravastatin
HMG-CoA reductase inhibitor
Male, 49 yo. Renal transplant 2 years ago, on ciclosporin + tacrolimus. Develops hypercholesterolaemia (LDL 4.1 mmol/L). Nephrologist wants…
Metabolism: Only statin with no CYP450 metabolism — fewest drug interactions of all statins; hydrophilic; half-life 1.8 h → optimally dosed in the evening
Fluvastatin
HMG-CoA reductase inhibitor
Male, 68 yo. Elective abdominal aortic aneurysm repair scheduled. LDL 3.2 mmol/L. On warfarin and phenytoin for epilepsy. Anaesthetist reque…
CYP2C9: Primary metabolism via CYP2C9 (not CYP3A4) — interacts with warfarin, phenytoin, fluconazole; avoids the CYP3A4 interaction burden of simvastatin/lovastatin
Pitavastatin
HMG-CoA reductase inhibitor
Female, 44 yo. HIV-positive, well-controlled on integrase inhibitor-based ART. LDL 3.5 mmol/L, fasting glucose 6.0 mmol/L (pre-diabetes). HI…
Metabolism: Metabolised primarily by CYP2C9 (minimal extent) — far fewer drug interactions than CYP3A4 statins; highest bioavailability of all statins (43–51%)
Ezetimibe
Cholesterol absorption inhibitor
Female, 66 yo. Known CAD on rosuvastatin 40 mg. LDL still 2.1 mmol/L despite maximal statin dose (target <1.4). No statin side effects. Card…
Mechanism: Inhibits NPC1L1 transporter on enterocytes — blocks dietary and biliary cholesterol absorption; LDL↓ ~18–20%
Fenofibrate
Fibrate — PPARα agonist
Male, 52 yo. Type 2 diabetes, poorly controlled. TG 9.2 mmol/L, HDL 0.7 mmol/L. Presents with severe epigastric pain — acute pancreatitis co…
Mechanism: PPARα agonist → ↑LPL activity, ↓apoC-III → TG reduction 40–55%; HDL↑ ~15%; preferred fibrate in statin combinations
Gemfibrozil
Fibrate — PPARα agonist
Male, 55 yo. Low HDL 0.8 mmol/L, TG 4.1 mmol/L, statin-intolerant (confirmed myalgia on two statins). GP starts a fibrate for mixed dyslipid…
Mechanism: PPARα agonist but also inhibits statin glucuronidation via UGT1A3 → dramatically raises statin plasma levels
Bempedoicacid
ATP-citrate lyase inhibitor
Female, 71 yo. Established ASCVD. LDL 3.2 mmol/L. Has tried four statins — all caused confirmed disabling myalgia on rechallenge. Refuses in…
Mechanism: Inhibits ATP-citrate lyase (ACL) — upstream of HMG-CoA reductase in mevalonate pathway; prodrug activated by hepatic ACSVL1 only
Evolocumab
PCSK9 inhibitor — monoclonal antibody
Male, 34 yo. Heterozygous familial hypercholesterolaemia confirmed genetically. On rosuvastatin 40 mg + ezetimibe — LDL still 4.8 mmol/L. Te…
Mechanism: Human IgG2 mAb binds PCSK9 — prevents LDL receptor degradation → recycled receptors → LDL↓ 50–65% on top of statin
Alirocumab
PCSK9 inhibitor — monoclonal antibody
Female, 61 yo. STEMI 8 weeks ago, successfully stented. On atorvastatin 80 mg + ezetimibe. LDL 2.8 mmol/L (target <1.4). Cardiologist initia…
Mechanism: Human IgG1 mAb vs PCSK9; same receptor-recycling mechanism; LDL↓ 46–67% on top of maximally tolerated statin
Inclisiran
PCSK9 inhibitor — siRNA therapy
Male, 69 yo. High CV risk. LDL 3.1 mmol/L despite maximum statin + ezetimibe. Was prescribed a PCSK9 monoclonal antibody but stopped after 3…
Mechanism: siRNA — silences PCSK9 mRNA in hepatocytes via GalNAc-conjugate targeting the asialoglycoprotein receptor; intracellular action
Colesevelam
Bile acid sequestrant — 2nd generation
Female, 58 yo. Type 2 diabetes on metformin, HbA1c 7.8%. LDL 3.0 mmol/L, TG 1.8 mmol/L. Cannot tolerate statins (confirmed myopathy), refuse…
Mechanism: Non-absorbed polymer binds bile acids in the gut → interrupts enterohepatic circulation → hepatic LDL receptor upregulation
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