16 July 2024: Articles
Rhabdomyolysis Risk: The Dangers of , an Over-the-Counter Supplement
Challenging differential diagnosis, Unusual or unexpected effect of treatment, Diagnostic / therapeutic accidents, Rare disease, Adverse events of drug therapy, Clinical situation which can not be reproduced for ethical reasons
Ross Huff12AEF*, Katarzyna Karpinska-Leydier12EF, Gautam Maddineni12EF, Dustin Begosh-Mayne12EFDOI: 10.12659/AJCR.943492
Am J Case Rep 2024; 25:e943492
Abstract
BACKGROUND: Over-the-counter (OTC) supplement use is a very common practice within the United States. Supplements are not tightly regulated by the Food and Drug Administration. There are many case reports involving OTC supplement adverse effects and medication interactions, but there remains minimal clinical research regarding these subjects. Rhabdomyolysis is one interaction and adverse effect frequently documented in case reports among a variety of OTC supplements, although, to date, there is no documentation of rhabdomyolysis occurring from an interaction between the supplement Tribulus terrestris and atorvastatin.
CASE REPORT: A 71-year-old man presented to the Emergency Department in rhabdomyolysis with a mild transaminitis after taking the over-the-counter supplement Tribulus terrestris while on long-term atorvastatin. His rhabdomyolysis peaked at day 4 after cessation of the Tribulus and atorvastatin and aggressive fluid resuscitation with a normal saline bolus at admission followed by a D5 sodium bicarbonate drip later transitioned to a normal saline drip with subsequent down-trending of the creatinine phosphokinase levels.
CONCLUSIONS: Tribulus terrestris is an herbal supplement used for erectile dysfunction and energy. Recent research suggests it to be a moderate CYP 3A4 inhibitor that plays a significant role in metabolism of statin and many other commonly prescribed medications. This may put patients at increased risk of developing serious adverse effects, including rhabdomyolysis and drug-induced liver injury. Screening patients for over-the-counter supplement use and educating them on the potential risks of their use is extremely important for inpatient and outpatient healthcare professionals to avoid dangerous medication interactions.
Keywords: Cytochrome P-450 CYP3A, Dietary Supplements, Drug-Related Side Effects and Adverse Reactions, rhabdomyolysis, Transaminases, Tribulus
Introduction
Rhabdomyolysis is a breakdown (“lysis”) of the muscle cells in the body, leading to a variety of symptoms and complications, including myalgias, hyperkalemia, and acute kidney injury [1–3]. This pathological process has many causes, with trauma and drug-induced being the most common. Drug-induced rhabdomyolysis is well described, especially among the statin medication class [1–3]. Rhabdomyolysis contributed to by herbal supplementation, including but not limited to licorice, red yeast rice, and jimson weed, is less well described, but there are reports found in the literature [4,5]. An area where there remains a paucity of research involves drug interactions between the statin medication class and herbal supplements. We describe what we believe to be the first known case of a medication-supplement-induced interaction between atorvastatin and the herbal supplement
Case Report
A 71-year-old man with a past medical history of coronary artery disease and hyperlipidemia presented to the Emergency Department for chest pain onset that morning. He woke up in his usual state of health but developed worsening cramping muscular pains in his extremities, which progressed into his chest. He denied any recent trauma or illnesses. He had no history of renal dysfunction or thyroidal illness. He admitted to drinking 3–4 beers on the weekend but denied any history of recreational drug use. He cycles 15 miles once a week for exercise but had not since the prior week. Medications included baby aspirin 81 mg daily, metoprolol succinate 100 mg daily, and long-term atorvastatin 40 mg daily. He had recently begun taking the supplement
Discussion
While statin-induced myopathy is a commonly known adverse effect, with rhabdomyolysis being the most severe form, there is a low risk of it occurring. Clinical studies show the risk of serious muscle injury from statin use is <0.1%, with the highest risk occurring within the first year of treatment, increasing the dosage, or addition of an interacting drug [6]. Our patient had been on high-intensity atorvastatin for 6 years without complication until recent initiation of the herbal supplement
Conclusions
Herbal supplementation is a common practice with minimal regulation or safety profile research, which opens the door for dangerous adverse effects and medication interactions among unsuspecting patients. Patients often do not readily mention over-the-counter supplements when asked about their home medications, so it is the physician’s responsibility to actively screen patients regarding supplement use, both inpatient and outpatient, and provide the necessary education to prevent harm. Physicians and other healthcare professionals need to be aware of the commonly used and emerging supplements such as
Figures
Figure 1.. Trend of the creatinine phosphokinase levels from admission at day 1 up until discharge on day 6. Levels peaked on day 4 at 11 972U/L, then rapidly declined. Figure 2.. Trend of the alanine aminotransferase and aspartate aminotransferase levels from admission on day 1 up until discharge on day 6. AST followed a similar up-trend to the creatinine phosphokinase levels, peaking on day 4 and subsequently down-trending, which is often seen in rhabdomyolysis. ALT followed a slower up-trend and had not shown a peak, with evidence of down-trending prior to discharge. ALT commonly trails the AST in its peak and its down-trend. As the peak was not observed, the patient was directed to follow-up for repeat lab draws as an outpatient; however, this was either not completed or was not uploaded into the patient medical information system.References:
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6.. Newman CB, Preiss D, Tobert JA, Statin safety and associated adverse events: A scientific statement from the American Heart Association: Arterioscler Thromb Vasc Biol, 2019; 39(2); e38-e81
7.. Ștefănescu R, Tero-Vescan A, Negroiu A: Biomolecules, 2020; 10(5); 752
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Figures
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