A case of rosuvastatin-induced rhabdomyolysis: More is not better

A 67-year-old female presented to the emergencydepartment with a 2-week history of progressivenausea, vomiting, abdominal pain, muscle cramps,and dehydration with an associated 3.6 kg weightloss. The patient had amedical history significantfor hypertension, hyperc-holesterolemia, myocardialinfarction, quadruple coro-nary artery bypass, asthma,and osteoarthritis. Medica-tions included enteric-coated acetylsalicylic acid81 mg daily, cilazapril 5 mgdaily, diltiazem CD 240 mgdaily, rosuvastatin 80 mgdaily, ezetimibe 10 mg daily,venlafaxine XL 75 mg daily,Advair (salmeterol/fluticasone) inhaler 250 mcg 1puff twice daily, Didrocal (calcium carbonate oretidronate) 1 tablet daily, glucosamine 1500 mgdaily, and ranitidine 150 mg twice daily. Vital signsat presentation included blood pressure 132/60mm Hg, heart rate 72 beats/minute, respiratoryrate 16 breaths/minute, and oxygen saturation 96%on room air. Abnormal findings on initial physicalexam indicated a mildly tender abdomen in all 4quadrants and reduced skin turgor, but the remain-der of the physical exam was unremarkable. Base-line laboratory tests indicated the following abnor-mal results: potassium 5.9 mmol/L, blood ureanitrogen 40.3 µmol/L, serum creatinine 1035µmol/L, creatine kinase (CK) 30,509 U/L, urinarymyoglobin >30,000 mcg/L, aspartate aminotrans-ferase 539 U/L, alanine aminotransferase 393 U/L,lactate dehydrogenase 1239 U/L. Urinalysis waspositive for red blood cellsand protein, and was nitritenegative, and a 12-leadelectrocardiogram indi-cated normal sinus rhythmwith no ischemic changes. Further history regard-ing the use of cholesterol-lowering agents revealedthe patient was initiated onsimvastatin 40 mg daily fol-lowing a myocardial infarc-tion 9 years previously, andwas switched to atorvas-tatin 20 mg daily 1 year later. The atorvastatin dosewas increased gradually over 4 years to 80 mg daily,but failed to achieve target low-density lipoproteincholesterol (LDL-C). Three years prior to presen-tation, ezetimibe 10 mg daily was added, whichresulted in an LDL-C reduction to 2.4 mmol/L.However, 7 months prior to presentation, atorvas-tatin 80 mg daily and ezetimibe 10 mg daily hadbeen inadequately controlling her cholesterol(LDL-C 2.9 mmol/L) and as a result atorvastatinwas switched to rosuvastatin 40 mg daily. Twomonths later, again due to inability to reach targetLDL-C, the dose of rosuvastatin was increased to