Severe rosuvastatin accumulation with rhabdomyolysis due to drug interactions and low cardiac output syndrome

Clinical conundrums involving statin drug-drug interactions

Statins are the cornerstone of pharmacologic therapy for the prevention and treatment of atherosclerotic cardiovascular disease. While they are generally considered safe, statins can be affected by drug-drug interactions (DDIs) that increase their systemic exposure increasing the risk for statin-associated muscle symptoms. These interactions are primarily mediated through metabolizing enzymes such as cytochrome P450 isoenzymes and membrane-bound drug transporting proteins including P-glycoprotein and organic ion transporting polypeptide. Recognition and avoidance of clinically significant statin DDIs is important to ensure their safe use. Conversely, concern over statin DDIs that are not clinically significant may lead to inappropriate underutilization or avoidance of statins in patients who would benefit from them. While many statin DDIs are well-characterized, we present several others that are less-well-established which may warrant clinical attention.

Approaches to management of rhabdomyolysis as the adverse effect of drug interaction between atorvastatin and sacubitril/valsartan: a case report

Background

Atorvastatin and sacubitril/valsartan (Entresto™) have been cornerstones in managing patients with coronary artery disease and heart failure (HF). We report a case of life-threatening rhabdomyolysis associated with the co-administration of atorvastatin and sacubitril/valsartan.

Case summary

A 58-year-old male with coronary heart disease and chronic HF treated with the optimal dose of atorvastatin and other cardiovascular medications was frequently admitted for acute decompensation of HF. We decided to optimize his condition by adding sacubitril/valsartan to his treatment regime. He presented to our outpatient clinic with worsening myalgia and oliguria 6 days later. He was readmitted with markedly elevated serum creatinine kinase (CK) (94 850 U/L; normal range 32–294 U/L), deranged liver function tests, and acute kidney injury. We withheld atorvastatin and sacubitril/valsartan and treated him with renal replacement therapy.

Discussion

Sacubitril inhibits the excretion of statins, thereby elevating serum statin concentration and increasing the likelihood of developing muscle-related toxicity. Co-administration of atorvastatin and sacubitril/valsartan should be monitored closely with laboratory investigations of CK and liver and renal function. The physician may consider starting low-dose atorvastatin at 20 mg daily in combination with sacubitril/valsartan 24 mg/26 mg twice daily and titrating accordingly to optimal doses. Rosuvastatin could be an alternative to atorvastatin, as it has less drug–drug interaction with sacubitril, thereby reducing the adverse effect.

Potential Safety Signals for Rhabdomyolysis Associated With High-Potency Statin Use With or Without Sacubitril/Valsartan

Regarding the drug interactions between sacubitril/valsartan and statins, we identified 3 reports of rhabdomyolysis with high-potency statins. However, it remains unknown whether the combined use of these medications could lead to additive or synergistic effects on rhabdomyolysis. This study aims to assess the disproportionality in reporting rhabdomyolysis for these medications when used alone or in combination. Case reports from the United States Food and Drug Administration's Adverse Event Reporting System from 1991 to Q4/2020 were used. Queries extracted reports based on exposure to statins alone, sacubitril/valsartan alone, and statin+sacubitril/valsartan each. Proportional reporting ratios (PRR) and 95% confidence intervals (CIs) were calculated, where a lower limit of the 95% CI (Lower 95% CI) value of ≥2.0 was interpreted as a safety signal. Lower 95% CIs for statins other than rosuvastatin alone demonstrated no potential safety signals for rhabdomyolysis, death, or the control event. The PRRs and 95% CI for rhabdomyolysis were 2.39 (2.01 to 2.84) with rosuvastatin alone and 2.06 (2.01 to 2.12) for sacubitril/valsartan alone. For atorvastatin+sacubitril/valsartan, the PRR and 95% CI were 0.95 (0.64 to 1.40). Statin+sacubitril/valsartan was not associated with a safety signal. However, rosuvastatin alone and sacubitril/valsartan alone were associated with rhabdomyolysis.

A Rare Adverse Event of Rhabdomyolysis Caused by Sacubitril/Valsartan

Rhabdomyolysis is caused by extensive damage to skeletal muscles resulting in elevated creatine phosphokinase (CPK), Lactate dehydrogenase (LDH), and aspartate aminotransferase (AST), leading to life-threatening consequences like acute renal failure, cardiac arrhythmias, and hyperthermia. A variety of causes for muscle damage are known, and one of the most common is drug-induced. Statins and many other agents are known to induce muscle damage, but here we report Entresto™ (Sacubitril/Valsartan) induced rhabdomyolysis which has not been previously reported as solely responsible in the literature.