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International Journal of Medicine and Medical Sciences ISSN: 2167-0447 Vol. 2 (12), pp. 269-270, December, 2012.
Available online at www.internationalscholarsjournals.org International Scholars Journals
Rosuvastatin induced rhabdomyolysis – Rare case
reported in Batticaloa
Pirasath S.1*, Jasotharan V.2, Sundaresan K. T.3
1 Post Intern Medical Officer, Teaching Hospital, Batticaloa.
2Medical student, Faculty of Health Care Sciences, Eastern University of Sri Lanka.
3Consultant Physician, Teaching Hospital, Batticaloa
Received 09 July, 2012; Accepted 12 December, 2012
We reported a case of rosuvastatin induced rhabdomyolysis in a patient, who presented with one week
history of bilateral thigh, back and shoulder pain and easy fatigability associated with passing dark
coloured urine for two days. His systemic examination reveals muscle tenderness. His investigations
showed high blood urea (147 mg%), serum creatinine (2.4mol/L), creatine kinase (CK) (21,210 U/L) and
with a significant increase in urine myoglobin. Even he has no risk factors; he was diagnosed as
rosuvastatin induced rhabdomyolysis associated with acute renal failure. The drug was stopped on the
first day of admission and the patient was initiated on intravenous fluid with cautious monitoring of
serum electrolytes. On the following days, the level of creatine kinase and serum myoglobin returned
towards normal and consequently he was discharged without statins but on dietary therapy. On follow-
up evaluation, the patient was symptoms free, his serum creatinine was 0.7mol/L, whereas his LDL
cholesterol was 119mg/dL. The rosuvastatin induced rhabdomyolysis is discussed and the danger of its
use in low risk patients is emphasized.
Cytochrome P450, rhabdomyolysis, rosuvastatin.
Statins are 3-hydroxy-3-methyl coenzyme A (HMG-
levels by 54%, while it increased HDL cholesterol by
CoA) reductase inhibitors that have significant effects
13% after 96 weeks . Like other statins, rosuvastatin
on the plasma lipid and lipoprotein profile, lowering total
is associated with a spectrum of adverse events
and LDL cholesterol and triglyceride levels and raising
ranging from mild to life-threatening. The most severe
HDL cholesterol levels;
currently they are the mainstay
adverse event is severe myopathy (ranges from
of dyslipidemia management for the primary and
myalgias to rhabdomyolysis), which can cause acute
secondary prevention of cardiovascular disease.The
renal failure; this adverse event usually associated with
use of statins in randomized trials has demonstrated
many risk factors. In this report we present a case of
30% reductions in atherosclerotic end points without
rhabdomyolysis induced by low dose of rosuvastatin (10
serious morbidity . Rosuvastatin is a competitive
mg daily) in a 62-year-old Batticaloa man who had no
inhibitor of the enzyme HMG-CoA reductase, having a
obvious risk factor.
mechanism of action similar, yet higher efficacy, to
other statins . The efficacy of rosuvastatin across its
dose range of 10 to 40 mg is superior to that of other
statins across their dose range,although the safety is
similar . Rosuvastatin 40 mg reduced LDL cholesterol
A 62 year-old Batticaloa man admitted with one week
history of bilateral thigh, back and shoulder pain and
easy fatigability associated with passing dark coloured
urine for two days. He denied the consumption of
*Corresponding author. E-mail: selladuraipirasath81@g
grapefruit juice or alcohol abuse and he hadn't had any
exercise before this episode. There was no family
Pirasath et al 269
history of muscle disease. The patient had history of
reported . Like other statins, rosuvastatin can cause
diabetes mellitus (DM) type II, hypertension and
life threatening rhabdomyolysis . Our patient
hypercholesterolemia. He had hypertension since for 20
presented with bilateral thigh back and shoulder pain
and easy fatigability associated with passing dark urine.
hypercholesterolemia for 2 years and had been
His serum creatinine was higher than the baseline and
followed up regularly by his physician in the clinic.
his CK was greater than 20 times the upper limit of
Current medications included metformin 500mg thrice
normal. The incidence of rosuvastatin- induced
daily orally (PO) and losartan 50mg once daily. His
rhabdomyolysis is not known exactly but it was
presumed to be low , and similar to atrovastatin,
atrovastatin 20 mg/ day for 2 years, but the patient was
pravastatin, and simvastatin ; to our knowledge this is
shifted to rosuvastatin 10 mg once daily PO during the
the first reported case in Batticaloa and even in low
last 2 months for better control of hypercholesterolemia.
dose of Rosuvastatin (10mg). Although statin induced
On examination the pulse was 84/min and the blood
rhabdomyolysis has been reported at rates of 1 death
pressure 150/95 mmHg. His systemic examination
per 6.6million prescriptions , no deaths related to
reveals muscle tenderness in bilateral thigh. The
rosuvastatin induced rhabdomyolysis were reported in
remaining of the examination was unremarkable.
the literature . Heerey et al.
 estimated that
Initial investigations showed hemoglobin level of 11.9
approximately 30% of all users of statins have
g/ dL, total leucocyte count 8700/mL and platelets,
concomitant prescribed drugs that can inhibit statin
479,000/uL; blood urea 147mg/dL, creatinine 2.4mg/dL,
metabolism by hepatic cytochrome P450 (CYP) system,
sodium 130.3 mEq/L and potassium 4.32 mEq/L,
potentially leading to rhabdomyolysis. The factors that
bicarbonate 23 mmol/L, Ca 2.3 mmol/L, blood sugar
increase the risk of rosuvastatin induced myopathy or
130mg/dL. His myoglobin was elevated, 2694 ng/ml
with a significant increase in urine myoglobin. The
impairment, hypothyroidism, personal or family history
creatine kinase (CK) level was markedly elevated
of hereditary muscular disorders, previous history of
(21,210 U/L).Aspartate aminotransferases (AST) was
muscular toxicity with another statin or fibrate,
89 IU/L, alanine aminotransferase (ALT) 60 IU/L and
consumption of grapefruit juice (more than 1 L per day),
alkaline phosphatase 341 IU/L. Total bilirubin was
alcohol abuse, being of Chinese or Japanese descent,
5mol/L, total proteins, 7.5 g/dL, and albumin, 4.0 g/dL,
concomitant use of fibrates. This group of patients
whereas PT and INR were normal. His fasting lipid
should be given rosuvastatin with caution .Our
patient had no obvious risk factors; he was 62 years old
cholesterol, 119mg/dL; triglyceride, 155mg/dL. His
and non alcoholic and nonsmoker; his baseline
previous investigations during clinic follow up before
creatinine was normal and the calculated creatinine
clearance was normal. Rosuvastatin should be
discontinued in patients with a creatine kinase level of
seemed the most likely diagnosis; accordingly this drug
more than 10 times the ULN with or without muscle
was stopped at time of admission and intravenous fluids
symptoms . Liver transaminase levels should be
(normal saline) given at 150 cc/hour with cautious
assessed at baseline, at 12 weeks after the start of
monitoring of serum electrolytes. Other medications
therapy or an increase in dose, and at 6-month intervals
were resumed. On the following days the level of
thereafter. The dosage should be reduced or therapy
creatine kinase and serum myoglobin declined toward
withdrawn if liver transaminase levels exceed 3 times
the normal value and consequently he was discharged
the ULN.Because of the potential for rosuvastatin to
10 days after hospitalization without statins but on diet
increase liver transaminase levels, it should be used
therapy. At the time of discharge, his baseline
with caution in patients with a history of liver disease or
investigations are normal. On follow-up evaluation two
alcohol abuse .Overall, persistent elevations in liver
months after discharge the patient was symptom free;
transaminase levels are reported in 0.1-0.4% of patients
laboratory evaluation yielded CK of 212 U/L, serum
taking rosuvastatin 5-40 mg . Similarly, our patient
creatinine of 0.7mg/L and LDL cholesterol of 119mg/dL.
showed high transaminase level which was returned to
normal after discontinuation of the drug. Although the
exact mechanism of statin-induced rhabdomyolysis is
unknown, the implicated mechanisms include the
followings: first, the cholesterol synthesis blockage;
Rosuvastatin is a relatively new cholesterol-lowering
which makes the skeletal muscle-cell membranes
drug in Sri Lanka as well as in other countries; although
unstable due to low cholesterol content . Second,
highly efficacious, this new statin has generated
prenylated protein abnormalities causing imbalances in
considerable controversy regarding its safety. In
intracellular protein messaging . Third, coenzyme
Canada as well as United States, many cases of
rosuvastatin induced rhabdomyolysis have been
respiratory function . Rosuvastatin induced rhabdom
270 Int. J. Med.Med.Sci.
yolysis in this patient is supported by the following: first,
De Pinieux G, Chariot P, Ammi-Said M, et al.
among the drugs used by the patient, there was no drug
lowering drugs and mitochondrial function: Effects of
HMG-CoA reductase inhibitors on serum ubiquinone
myoglobin and CK were washed out from the blood and
and blood lactate/ pyruvate ratio. Br. J. Clin.
returned towards normal within few days after
Pharmacol. 1996; 42: 333-337.
discontinuation of rosuvastatin. In conclusion, although
Flint OP, Masters BA, Gregg RE, Durham SK. Inhibition
of cholesterol synthesis by squalene synthase
considerable controversy regarding its safety; clinicians
inhibitors does not induce myotoxicity in vitro
should maintain an increased level of awareness of the
Appl Pharmacol 1997; 145: 91-98.
potential for muscle toxicity and rhabdomyolysis, which
Heerey A, Barry M, Ryan M, Kelly A. the potential for
associated with this new drug even with low dose.
drug interactions with statin therapy in Ireland. Ir J.
Accordingly, Emergent myalgias in patients under
Med. Sci. 2000; 169: 176-9.
rosuvastatin necessitate immediate testing of creatine
Shepherd J, Vidt DG, Miller E, Harris S, Blasetto J.
kinase and myoglobin to exclude life threatening
rhabdomyolysis even with low dose.
rosuvastatin-treated patients in a multinational clinical
trial program. Cardiology 2007; 107: 433-43.
Staffa JA, Chang J, Green L. Cerivastatin and reports of
fatal rhabdomyolysis. N. Engl. J. Med. 2002; 346:
Stein EA, Amerena J, Ballantyne CM, et al.
Antons KA, Williams CD, Baker SK, Phillips PS. Clinical
efficacy and safety of rosuvastatin 40 mg in patients
perspectives of statin-induced rhabdomyolysis. Am. J.
with severe hypercholesterolemia. Am. J. Cardiol.
Med. 2006; 119: 400-9.
2007; 100: 1387-96.
Thompson PD, Clarkson P, Karas RH. Statin-
rhabdomyolysis [Dear Health Care Professional
associated myopathy. JAMA 2003; 289: 1681-90.
letter]. Mississauga (ON): Astra Zeneca Canada Inc.; 2004
//napra.ca/pdfs/advisories/ crestorhc.pdf [accessed 2008 July 28].
Wilmington, DE; 2003.
Brewer HB Jr. Benefit-risk assessment of rosuvastatin
10 to 40 milligrams. Am. J. Cardiol. 2003; 92: 23-29.
Cannon CP, Braunwald E, McCabe CH, et al.
versus moderate lipid lowering with statins after acute coronary syndromes. N. Engl. J. Med. 2004; 350: 1495-1504.
Expert Evidence Report - Survival of the "Fryest": A Review of Recent State.d a 50 State Survey of the Standards for Admissibility of Expert Testimony. Volume 2 Number 5 Monday, March 18, 2002ISSN 1536-190X Survival of the "Fryest": A Review of Recent State Supreme Court Decisions Analyzing Frye's General Acceptance Standard and a 50 State Survey of the Standards for Admissibility of Expert Testimony.
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