Low-dose atorvastatin therapy induced rhabdomyolysis in a liver cirrhosis patient - a case report

Introduction: Rhabdomyolysis may arise due to traumatic or non-traumatic causes leading to muscle injury. However, increased statin use has raised drug-related side effects like statin-related muscle damage. Case report: A 74-year-old male with liver cirrhosis secondary to alcohol was prescribed atorvastatin for hyperlipidemia. He developed muscle tenderness and decreased muscle power 2 weeks following statin therapy, evident with a creatine phosphokinase level of more than 22 000 IU/l. The urinalysis also revealed positive for blood. Hence, atorvastatin was ceased. The patient's laboratory parameters improved significantly, implying atorvastatin is the causative agent for rhabdomyolysis. Discussion: Statins are usually safe and well-tolerated drugs; however, skeletal muscle symptoms occur in similar to 5-10% of patients. The risk factor for statin-induced muscle injury includes advanced age, drug-altering statin plasma level, liver disease, or chronic kidney disease. Moreover, the hepatic level of CYP450 and its CYP3A4 isoform are altered in chronic liver diseases. CYP3A4 isoenzyme and its activity declines in hepatic cirrhosis patients. Conclusion: Statins are generally prescribed for hyperlipidemia and primary and secondary prevention in high-risk cardiovascular diseases. However, several risk factors alter statin metabolism, causing statin-induced muscle injury. Thus, despite several studies suggesting otherwise, special precautions should be taken in patients with chronic liver disease.