Treatment of fibrate-induced rhabdomyolysis with plasma exchange in ESRD

Fenofibrate monotherapy-induced rhabdomyolysis in a patient with post-pancreatitis diabetes mellitus: A rare case report and a review of the literature

RATIONALE

Fibrates are widely used to control hypertriglyceridemia and mixed dyslipidemia alone or in combination with statins. These drugs have rare, but severe and potentially vital adverse reactions of rhabdomyolysis and secondary acute renal failure (ARF). The objective of this article is to analyze this adverse effect of fibrates and ensure the safety of drug use.

PATIENT CONCERNS

We report a case of rhabdomyolysis and ARF due to fenofibrate monotherapy in a 68-year-old female with post-pancreatitis diabetes mellitus and review reported cases of rhabdomyolysis correlated with fibrates monotherapy.

DIAGNOSIS

The patient was diagnosed with rhabdomyolysis associated with fenofibrate monotherapy as confirmed by symptoms of fatigue and muscle pain, and elevated levels of myoglobin and creatine kinase.

INTERVENTIONS

Fenofibrate therapy was discontinued. Moreover, intravenous fluids, urinary alkalization, and diuretic were performed.

OUTCOMES

The symptoms were completely relieved, and relevant laboratory indexes returned to normal range during follow-up.

LESSONS

Physicians should be aware of the side effect of rhabdomyolysis of fibrates, and patients should also be informed about this potential side effect, especially for patients with high-risk factors. A favorable outcome can be achieved by timely diagnosis and prompt treatment.

Therapeutic plasmapheresis and red blood cell exchange in a sickle cell trait patient with rhabdomyolysis

We report a case of a 16-year-old African-American male with sickle cell trait and a past medical history significant for asthma that was transferred to our hospital for management of respiratory failure. On the fourth day of hospitalization, the patient was found to have increased creatine kinase (CK) levels and urine myoglobin levels consistent with rhabdomyolysis. No clear etiology was identified. Aggressive standard hydration and urine alkalization were applied without response. On the sixth day of hospitalization, the patient underwent a 1-1.5 plasma volume therapeutic plasma exchange (TPE) resulting in a transient reduction of serum CK and myoglobin by 50%, which became elevated once again within 4 h. Since his clinical presentation resembles exertional rhabdomyolysis documented in patients with sickle cell trait, RBC exchange was performed. The patient tolerated the procedure without complications. In addition to his improved overall condition, the patient's post-exchange CK and serum myoglobin levels dropped dramatically without rebound. To our knowledge, this case represents the first reported case of TPE followed by RBC exchange in a SCT patient with rhabdomyolysis.

Bezafibrate induces myotoxicity in human rhabdomyosarcoma cells via peroxisome proliferator-activated receptor alpha signaling

Fibrates, the ligands of peroxisome proliferator-activated receptor alpha (PPARalpha), are used as a class of lipid-lowering drugs in clinical practice for the treatment of dyslipidemia. Fibrates are well tolerated in most cases concomitantly with occasional adverse reactions including muscular toxicity, which is enhanced by the combination with statins. This study was designed to investigate the effects of bezafibrate as a PPARalpha agonist on human embryo rhabdomyosarcoma (RD) cells and possible mechanisms responsible for bezafibrate-mediated myopathy. The results revealed that bezafibrate caused a dose-dependent decrease in cell viability, which was fortified in association with atorvastatin at a pharmacological dose. Bezafibrate at toxic doses of 300 and 1000microM upregulated PPARalpha at the mRNA level, counteracted by a PPARalpha antagonist (MK886). Bezafibrate at a toxic dose induced typical apoptotic characteristics related to the inhibition of phosphorylation of Akt which was blocked by PPARalpha antagonist. Toxic doses of bezafibrate initiated a significant increase in pyruvate dehydrogenase kinase 4 mRNA and protein levels, compromised by MK886. These results suggest the critical roles of PPARalpha signaling in bezafibrate-induced myotoxicity and the involvement of apoptosis through Akt pathway.

Plasmapheresis in a patient with rhabdomyolysis: a case report

INTRODUCTION

Cardiovascular benefits and improved survival have resulted in statins becoming the most prescribed drugs in USA. There is a small but significant risk of developing statin induced rhabdomyolysis especially in combination with other lipid lowering medications for example fibrates like Gemfibrozil.

CASE PRESENTATION

We describe a case of an 82 year old male patient who developed rhabdomyolysis while taking a combination of Simvastatin and Gemfibrozil and was successfully managed with plasmapheresis.

CONCLUSION

There are only a few cases of rhabdomyolysis treated with plasmapheresis reported in literature. Most of the case reports of using this technique in rhabdomyolysis have been from Asia, Australia and Europe. We suggest that plasmapheresis may be considered as an option in severe life threatening rhabdomyolysis.

Fenofibrate-induced acute renal failure due to massive rhabdomyolysis after coadministration of statin in two patients

Fibric acid derivatives and statins have been increasingly recognized as causes of rhabdomyolysis and acute renal failure. We report severe rhabdomyolysis and acute renal failure associated to combination treatment with statin and fenofibrate in two patients with underlying coronary artery disease. Both patients developed rhabdomyolysis-induced acute renal failure after their hyperlipidemia treatment was changed from statin to statin plus fenofibrate. Both patients experienced intense muscle symptoms, hemoglobinuria, oliguria, and elevation of blood urea nitrogen and serum creatinine. Their serum creatine kinase levels were markedly elevated (case 1; 97,392 IU/l and case 2; 96,639 IU/l). Rhabdomyolysis induced acute renal failure was diagnosed in both patients. Both patients were managed with cessation of the statin-fibrate combination, adequate fluid resuscitation and forced alkaline-mannitol diuresis. Although both patients required hemodialysis, their renal function recovered. Fenofibrate initiation is associated with an increased risk for rhabdomyolysis in patients receiving statin therapy. To prevent future events, it is crucial that clinicians recognize the interaction risk associated with concurrent use of statin and fenofibrate. We recommend careful monitoring when fenofibrate is given to patients receiving statin therapy.

[Rhabdomyolysis induced by fenofibrate monotherapy]

INTRODUCTION

Rhabdomyolysis with fibrate have been reported when fibrate are associated with statin or during renal insufficiency or hypothyroidism.

CASE RECORD

We describe one patient with diabetes mellitus treated by fenofibrate monotherapy since several years; 48 h after gliclazide therapy was introduced, rhabdomyolysis occurred.

DISCUSSION

Responsibilities of deshydratation and / or drug interaction with gliclazide. are discussed.