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      Simvastatin-induced myoglobinuric acute kidney injury following ciclosporin treatment for alopecia universalis

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          Abstract

          Alopecia areata can affect the entire scalp (alopecia totalis) or cause loss of all body hair (alopecia universalis). Ciclosporin (CsA) has been suggested for its treatment, with controversial results. Concomitant use of statins and CsA may increase the risk of rhabdomyolysis due to drug–drug interactions.

          Here we report the case of a 45-year-old woman treated with CsA for alopecia universalis, who presented a severe myoglobinuric acute kidney injury following the concomitant use of simvastatin. Upon admission to our unit, she was oligo-anuric. Her serum creatinine level was 13.8 mg/dl. CsA and simvastatin therapy were stopped, and haemodialysis treatment was started (eight daily dialysis sessions) until sufficient kidney function was regained. After 1 month, her serum creatinine level was 3.5 mg/dl; after 2 months and onwards (follow-up of 4 months), her serum creatinine level was 1.4 mg/dl and creatinine clearance was 43.2 ml/min.

          In conclusion, physicians should be aware of the potential risks of the combined use of CsA and statins. Patients should be advised to report any muscle symptoms when they are on statins and CsA. The laboratory follow-up should include the monitoring of serum creatinine and muscle enzyme levels, blood CsA levels and liver function tests.

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          Most cited references 13

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          Statin-associated myopathy.

          Statins (3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors) are associated with skeletal muscle complaints, including clinically important myositis and rhabdomyolysis, mild serum creatine kinase (CK) elevations, myalgia with and without elevated CK levels, muscle weakness, muscle cramps, and persistent myalgia and CK elevations after statin withdrawal. We performed a literature review to provide a clinical summary of statin-associated myopathy and discuss possible mediating mechanisms. We also update the US Food and Drug Administration (FDA) reports on statin-associated rhabdomyolysis. Articles on statin myopathy were identified via a PubMed search through November 2002 and articles on statin clinical trials, case series, and review articles were identified via a PubMed search through January 2003. Adverse event reports of statin-associated rhabdomyolysis were also collected from the FDA MEDWATCH database. The literature review found that reports of muscle problems during statin clinical trials are extremely rare. The FDA MEDWATCH Reporting System lists 3339 cases of statin-associated rhabdomyolysis reported between January 1, 1990, and March 31, 2002. Cerivastatin was the most commonly implicated statin. Few data are available regarding the frequency of less-serious events such as muscle pain and weakness, which may affect 1% to 5% of patients. The risk of rhabdomyolysis and other adverse effects with statin use can be exacerbated by several factors, including compromised hepatic and renal function, hypothyroidism, diabetes, and concomitant medications. Medications such as the fibrate gemfibrozil alter statin metabolism and increase statin plasma concentration. How statins injure skeletal muscle is not clear, although recent evidence suggests that statins reduce the production of small regulatory proteins that are important for myocyte maintenance.
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            FDA adverse event reports on statin-associated rhabdomyolysis.

            To determine the number of cases of statin-associated rhabdomyolysis reported to the Food and Drug Administration for 6 statins and to profile the cases. A retrospective analysis of all domestic and foreign reports of statin-associated rhabdomyolysis between November 1997 and March 2000 was conducted. Outcome measures included the total number of reports (initial plus follow-up), the number of unique cases, age, gender, percentages of report codes and role codes, and frequencies of concomitant interacting drugs that may have precipitated rhabdomyolysis, outcomes codes, and report source codes. There were 871 reports of statin-associated rhabdomyolysis in the 29-month time frame examined, representing 601 cases. The following number of cases were associated with each of the individual statins: simvastatin, 215 (35.8%); cerivastatin, 192 (31.9%); atorvastatin, 73 (12.2%); pravastatin, 71 (11.8%); lovastatin, 40 (6.7%); and fluvastatin, 10 (1.7%). Drugs that may have interacted with the statins were present in the following number of cases: mibefradil (n = 99), fibrates (n = 80), cyclosporine (n = 51), macrolide antibiotics (n = 42), warfarin (n = 33), digoxin (n = 26), and azole antifungals (n = 12). The reports of 62.1% of cases were classified as expedited. Statins were designated as the primary suspect in 72.0% of the cases. Death was listed as the outcome in 38 cases. The majority of reports (n = 556) were from health professionals. Compared with the other statins, simvastatin and cerivastatin were implicated in a relatively higher number of reports. Because of the various limitations of a spontaneous reporting-system database, caution is urged when interpreting the relative number of cases reported.
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              In vitro metabolism of simvastatin in humans [SBT]identification of metabolizing enzymes and effect of the drug on hepatic P450s.

              Simvastatin (SV) is a lactone prodrug used for the treatment of hypercholesterolemia. Upon incubation of SV with liver microsomal preparations from human donors, four major metabolic products were formed (3'-hydroxy SV, 6'-exomethylene SV, 3',5'-dihydrodiol SV, and the active hydroxy acid, SVA), together with several minor unidentified metabolites. The 3',5'-dihydrodiol SV, a new metabolite, was inactive as an inhibitor of HMG-CoA reductase. Kinetic studies of SV metabolism in human liver microsomes suggested that the major NADPH-dependent metabolites (3'-hydroxy SV, 6'-exomethylene SV, and 3',5'-dihydrodiol SV) were formed with relatively high intrinsic clearances, consistent with the extensive metabolism of SV observed in vivo. Based on four different in vitro approaches, namely 1) correlation analysis, 2) chemical inhibition, 3) immunoinhibition, and 4) metabolism by recombinant human P450, it is concluded that CYP3A is the major enzyme subfamily responsible for the metabolism of SV by human liver microsomes. Both CYP3A4 and CYP3A5 were capable of catalyzing the formation of 3',5'-dihydrodiol, 3'-hydroxy, and 6'-exomethylene metabolites. However, CYP3A4 exhibited higher affinity (> 3 fold) for SV than CYP3A5. Also, the studies indicated that CYP2D6, CYP2A6, CYP2C8, CYP2C9, CYP2C19, CYP1A2, and CYP2E1 did not play significant roles in the metabolism of SV in vitro. Over the concentration range of 0-40 microM, SV inhibited the activity of CYP3A, but not the activities of CYP2C8/9, CYP2C19, or CYP2D6 in human liver microsomes. The inhibition of hepatic midazolam 1'-hydroxylase, a CYP3A marker activity, by SV was competitive with a Ki value of approximately 10 microM. SV was > 30-fold less potent than ketoconazole and itraconazole as an inhibitor of CYP3A. Under the same conditions, SVA, the hydrophilic hydroxy acid form of SV, did not inhibit CYP3A, CYP2C8/9, CYP2C19, or CYP2D6 activities. The results suggested that the in vivo inhibitory effects of SV on the metabolism of CYP3A substrates likely would be less than those of ketoconazole and itraconazole at their respective therapeutic concentrations. In addition, metabolic activities mediated by the other P450 enzymes tested are unlikely to be affected by SV.
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                Author and article information

                Journal
                NDT Plus
                NDT Plus
                ckj
                ndtplus
                NDT Plus
                Oxford University Press
                1753-0784
                1753-0792
                June 2010
                28 February 2010
                28 February 2010
                : 3
                : 3
                : 273-275
                Affiliations
                Division of Nephrology and Dialysis, Miulli General Hospital , Acquaviva delle Fonti, Italy
                Author notes
                Carlo Basile; E-mail: basile.miulli@ 123456libero.it
                Article
                sfq012
                10.1093/ndtplus/sfq012
                5477947
                © The Author 2010. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved. For permissions, please e-mail: journals.permissions@oxfordjournals.org

                This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com

                Categories
                Case Report

                Nephrology

                simvastatin, myoglobinuria, ciclosporin, acute kidney injury

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