Delayed presentation of severe rhabdomyolysis leading to acute kidney injury following atorvastatin-gemfibrozil combination therapy: a case report

Abstract

BackgroundRhabdomyolysis is a rare but serious complication of lipid-lowering therapy. Statin and fibrate combination increases the risk of rhabdomyolysis possibly by pharmacodynamic interactions. Advanced age, diabetes, hypothyroidism, polypharmacy, and renal impairment are known to increase the risk of rhabdomyolysis. Management strategies include fluid resuscitation and urine alkalinization. Renal indications such as refractory hyperkalemia, acidosis, fluid overload, or uremic complications mandate renal replacement therapy in rhabdomyolysis.Case presentationWe report the case of a 62-year-old Sri Lankan Sinhalese man with dyslipidemia, type 2 diabetes mellitus with renal impairment, and hypothyroidism who was on atorvastatin; he was started on gemfibrozil and developed muscle symptoms. Although gemfibrozil was discontinued soon after, he presented with rhabdomyolysis with acute kidney injury 1 month later. He needed hemodialysis due to refractory hyperkalemia, metabolic acidosis, and fluid overload.ConclusionsRhabdomyolysis is a rare but serious complication due to lipid-lowering therapy with statins and fibrates. Treating physicians should be aware and patients should be warned to report about muscle symptoms after starting statins or fibrates. Rhabdomyolysis may occur with mild symptoms and signs and may occur later, even after discontinuation of the drug.

Rhabdomyolysis with Acute Kidney Injury Caused by Bilateral Iliopsoas Hematoma in a Patient with Atrial Fibrillation

“…It is mainly caused by trauma or non-traumatic factors, such as side effects of statins and infection. Patients with rhabdomyolysis who are complicated by AKI may require renal replacement therapy for renal indications, such as hyperkalemia, acidosis, or fluid overload not responding to medical therapy (2,3), and the prognosis of these patients is considered worse than that for patients without AKI (4).…”

Axial muscle weakness

“…Although intravenous immunoglobulin and high-dose intravenous melphalan with autologous peripheral blood stem cell transplantation (HDM-SCT) are standard treatments, our case responded to intravenous immunoglobulin and stopping gemfibrozil, suggesting that intravenous immunoglobulin monotherapy is a possible alternative to HDM-SCT in patients with sporadic late-onset nemaline myopathy. We cannot completely exclude a contribution from fibrate myopathy 30 in this case, although the finding of rods would be atypical. The search for other treatable causes for axial myopathies (figure 3) cannot be overemphasised.…”

Ascorbic Acid Greatly Decreases Creatine Kinase Levels in An Animal Model of Statin/Fibrate-Induced Myopathy

“…The incidence of myopathy with the simultaneous administration of some statins and gem brozil is estimated 1 to 5 percent (18,19), including rhabdomyolysis as the most severe form (4). Muscle toxicity can be reduced by changing the type of brate (e.g., feno brate is found to bring the lowest risk) and by using statins at relatively low doses because the adverse effect is dose-dependent (20,21).…”