Suspected Drug-Induced Rhabdomyolysis From the Combination of Atorvastatin, Amiodarone, and Ciprofloxacin

A systematic review of the drug-drug interaction between Statins and Quinolones

BACKGROUND

Statins are widely used in cardiovascular disease (CVD) as a common lipid-lowering drug, while quinolones are widely used for the treatment of infectious diseases. It is common to see CVD in combination with infectious diseases, therefore it is often the case that statins and quinolones are used in combination. Data suggest combinations of statin and quinolone may be associated with potentially life-threatening myopathy, rhabdomyolysis and acute hepatitis. This systematic review aims to characterize data regarding patients affected by the statin-quinolone interaction.

METHODS

The purpose of this systematic review was to collect and evaluate the evidence surrounding statin-quinolone drug interactions and to discuss related risk mitigation strategies. The following databases were searched: PubMed (Medline), Embase, Scopus, and Cochrane Library. The systematic electronic literature search was conducted with the following search terms. In this study, three types of search terms were used: statins-related terms, quinolones-related terms, and drug interactions-related terms.

RESULTS

There were 16 case reports that met the criteria for qualitative analysis. Patients were involved in the following adverse reactions: rhabdomyolysis (n = 12), acute hepatitis (n = 1), muscle weakness (n = 1), hip tendinopathy (n = 1), or myopathy (n = 1). In the included literature, patients vary in the dose and type of statins they take, including simvastatin (n = 10) at a dose range of 20-80 mg/d and atorvastatin (n = 4) at a dose of 80 mg/d. There were 2 patients with unspecified statin doses, separately using simvastatin and atorvastatin. The quinolones in combination were ciprofloxacin (n = 9) at a dose range of 800-1500 mg/d, levofloxacin (n = 6) at a dose range of 250-1000 mg/d, and norfloxacin (n = 1) in an unspecified dose range. 81% of the case patients were over 60 years of age, and about 1/3 had kidney-related diseases such as diabetic nephropathy, post-transplantation, and severe glomerulonephritis. Nearly two-third of the patients were on concomitant cytochrome P450 3A4 (CYP3A4) inhibitors, P-glycoprotein (P-gp) inhibitors, or organic anion transporting polypeptide 1B1 (OATP1B1) inhibitors.

CONCLUSION

Patients treated with statin-quinolone combination should be monitored more closely for changes in aspartate aminotransferase or creatine kinase (CK) levels, and muscle symptoms, especially in patients with ciprofloxacin or levofloxacin, with simvastatin and high-dose atorvastatin, over 60 years of age, with kidney-related diseases, and on concomitant CYP3A4 inhibitors.

Rhabdomyolysis Associated With Febuxostat in a Non-Chronic Kidney Disease (CKD) Patient: Diagnostic and Management Challenges

Rhabdomyolysis is a critical medical condition characterized by the rapid breakdown of muscle tissue, releasing substances such as myoglobin and creatine kinase into the bloodstream, potentially leading to acute kidney injury. The etiology includes trauma, exertion, genetic factors, infections, and adverse drug reactions. Febuxostat, a non-purine selective xanthine oxidase inhibitor used to manage hyperuricemia in gout patients, is typically well-tolerated but has been associated with rare instances of severe adverse reactions like rhabdomyolysis. This case report describes a case of a 73-year-old male who developed rhabdomyolysis shortly after initiating febuxostat for gout management. He presented with significant lower back pain and progressive leg weakness, initially suspected to be an exacerbation of his degenerative disk disease. Laboratory findings revealed alarmingly elevated creatine phosphokinase levels, and diagnostics excluded other potential etiologies. The patient's condition significantly improved following the cessation of febuxostat and initiation of supportive care, including high-dose intravenous corticosteroids and hydration. This case underscores the need for vigilance in monitoring for rhabdomyolysis in patients starting febuxostat, especially when presenting with unexplained muscle weakness or pain.