title: Rhabdomyolysis after concomitant use of cyclosporine, simvastatin, gemfibrozil, and itraconazole.
abstract: OBJECTIVE
  To report a case of rhabdomyolysis in a patient receiving cyclosporine, simvastatin, gemfibrozil, and itraconazole.
  
  
  METHODS
  Rhabdomyolysis occurring in transplant patients receiving both cyclosporine and the hydroxymethylglutaryl coenzyme A (HMG-CoA) reductase inhibitor lovastatin has been well documented. The exact mechanism by which this interaction leads to rhabdomyolysis is unknown. Experience with newer agents of the statin drug class in transplant patients is limited. Since the interaction between cyclosporine and HMG-CoA reductase inhibitors involves the CYP3A4 enzyme system, the possibility of amplifying this interaction exists when other drugs affecting the same enzyme system are coprescribed. We describe a case in which a heart transplant recipient stable on a drug regimen that included cyclosporine, simvastatin, and gemfibrozil developed rhabdomyolysis after initiation of the antifungal agent itraconazole.
  
  
  CONCLUSIONS
  Drug-drug interactions due to shared metabolism via the CYP3A4 pathway can result in significant adverse outcomes. This article discusses concurrent use of an HMG-CoA reductase inhibitor with other drugs that inhibit the CYP3A4 isoenzyme, leading to a case of possible fatal rhabdomyolysis.
  
  
  CONCLUSIONS
  Clinicians must be aware of drugs metabolized via cytochrome P450 isoenzymes and identify those requiring risk-versus-benefit analysis before prescribing. Patients need to be educated as to signs and symptoms requiring immediate physician intervention.
authors.affiliation: Baylor University Medical Center, 3500 Gaston Avenue, Dallas, TX 75246-2088, USA. janma@bhcs.com
authors.forename: Jan L
authors.initials: JL
authors.lastname: Maxa
authors.forename: Larry B
authors.initials: LB
authors.lastname: Melton
authors.forename: Chris C
authors.initials: CC
authors.lastname: Ogu
authors.forename: Michael N
authors.initials: MN
authors.lastname: Sills
authors.forename: Alex
authors.initials: A
authors.lastname: Limanni
mesh_terms: D000935:Antifungal Agents / Q000009:adverse effects / Q000627:therapeutic use; D016572:Cyclosporine / Q000009:adverse effects* / Q000627:therapeutic use; D051544:Cytochrome P-450 CYP3A; D065607:Cytochrome P-450 Enzyme Inhibitors; D003577:Cytochrome P-450 Enzyme System / Q000378:metabolism; D004347:Drug Interactions; D017809:Fatal Outcome; D015248:Gemfibrozil / Q000009:adverse effects* / Q000627:therapeutic use; D006801:Humans; D000960:Hypolipidemic Agents / Q000009:adverse effects / Q000627:therapeutic use; D007166:Immunosuppressive Agents / Q000009:adverse effects / Q000627:therapeutic use; D017964:Itraconazole / Q000009:adverse effects* / Q000627:therapeutic use; D008297:Male; D008875:Middle Aged; D006899:Mixed Function Oxygenases / Q000037:antagonists & inhibitors / Q000378:metabolism; D016377:Organ Transplantation; D012206:Rhabdomyolysis / Q000139:chemically induced*; D018570:Risk Assessment; D019821:Simvastatin / Q000009:adverse effects* / Q000627:therapeutic use
chemical_list: D000935:Antifungal Agents; D065607:Cytochrome P-450 Enzyme Inhibitors; D000960:Hypolipidemic Agents; D007166:Immunosuppressive Agents; D017964:Itraconazole; D016572:Cyclosporine; D003577:Cytochrome P-450 Enzyme System; D019821:Simvastatin; D006899:Mixed Function Oxygenases; C104464:CYP3A protein, human; D051544:Cytochrome P-450 CYP3A; C510163:CYP3A4 protein, human; D015248:Gemfibrozil