阿托伐他汀钙与克拉霉素并用致横纹肌溶解

Rhabdomyolysis induced by concomitant use of atorvastatin calcium and clarithromycin

1例62岁男性患者因冠状动脉粥样硬化性心脏病行经皮冠状动脉介入术后规范服用阿司匹林、氯吡格雷和阿托伐他汀钙;1周后,因合并幽门螺杆菌(Hp)感染,患者接受四联抗Hp药物治疗(阿莫西林胶囊、克拉霉素、胶体酒石酸铋胶囊、泮托拉唑钠肠溶片),用药2~3 d后患者出现全身乏力、恶心、关节不适、肌肉酸痛。实验室检查:血肌红蛋白(MYO)>1000 mg/L,血清肌酐(Scr)69 mmol/L,尿素氮(BUN)3.5 mmol/L,碱性磷酸酶(ALP)148 U/L,丙氨酸转氨酶(ALT)750 U/L,天冬氨酸转氨酶(AST)850 U/L,γ‑谷氨酰转肽酶(γ‑GT)181 U/L;乳酸脱氢酶(LDH)1177 U/L,肌酸激酶(CK)8144 U/L,CK‑MB 255 U/L。考虑可能为他汀类药物引起的横纹肌溶解症,停用该药,给予碱化尿液、补液等对症支持治疗,继续抗Hp治疗,但CK仍进行性升高。停用阿托伐他汀钙4 d后CK达15794 U/L。考虑患者横纹肌溶解可能与克拉霉素与阿托伐他汀钙的相互作用有关,遂停用抗Hp四联药物;停药第2天患者诉肌肉酸痛较前减轻;第4天CK等血清酶学指标开始下降;第8天患者乏力及肌肉酸痛完全消失,CK 908 U/L;第15天ALT 105 U/L、AST 42 U/L、γ‑GT 107 U/L、CK 143 U/L、CK‑MB 29 U/L、LDH 339 U/L;5周后患者再次服用阿托伐他汀钙,未再出现肌痛及乏力,复查血生化指标均未见异常。

A 62‑year‑old male patient received aspirin,clopidogrel,and atorvastatin calcium after percutaneous coronary intervention for coronary atherosclerotic heart disease.One week later,the patient received anti‑Helicobacter pylori(Hp)therapy with amoxicillin capsules,clarithromycin tablets,bismuth tartrate capsules,and pantoprazole sodium enteric coated tablets due to Hp infection,and two to three days after taking the drugs,the patient developed systemic fatigue,nausea,joint discomfort and muscle soreness,which were gradually aggravated.Laboratory tests showed muscle hemoglobin(MYO)>1000μg/L,serum creatinine(Scr)69 mmol/L,urea nitrogen(BUN)3.5 mmol/L,alkaline phosphatase(ALP)148 U/L,alanine aminotransferase(ALT)750 U/L,aspartate aminotransferase(AST)850 U/L,g‑glutamyl transpeptidase(γ‑GT)181 U/L,lactate dehydrogenase(LDH)1177 U/L,creatine kinase(CK)8144 U/L,CK‑MB 255 U/L.Atorvastatin calcium was stopped,and symptomatic and supportive treatments such as alkalized urine and fluid replacement were given,and anti‑Hp treatments were continued.However,the CK level was continued to increase.CK reached 15794 U/L 4 days after atorvastatin calcium discontinuation.It was considered that the patient′s rhabdomyolysis might be related to interaction between atorvastatin calcium and clarithromycin.Then the anti‑Hp drugs were discontinued.On the 2nd of drug withdrawal,the patients′muscle soreness was alleviated than before;on the 4th day,CK and other serum enzymology indexes began to decline;on the 8th day,the patient′s fatigue and muscle soreness completely disappeared,with CK 908 U/L;on the 15th day,ALT was 105 U/L,AST was 42 U/L,γ‑GT was 107 U/L,CK was 143 U/L,CK‑MB was 29 U/L,and LDH was 339 U/L;5 weeks later,the patient took atorvastatin again,myalgia and fatigue did not recur,and no abnormality was found in blood biochemical indexes.