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. 2019;7(12):337-341.
doi: 10.12691/ajmcr-7-12-9. Epub 2019 Oct 18.

Ticagrelor and Statin Interaction Induces Rhabdomyolysis and Acute Renal Failure: Case Reports and Scoping Review

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Free PMC article

Ticagrelor and Statin Interaction Induces Rhabdomyolysis and Acute Renal Failure: Case Reports and Scoping Review

Pramod Theetha Kariyanna et al. Am J Med Case Rep. .
Free PMC article

Abstract

Ever since evidence about the increased risk of stent thrombosis with drug eluting stents (DES) surfaced in 2005, the Food and Drug Administration (FDA) has recommended the use of dual antiplatelet therapy (aspirin with P2Y12 inhibitor) following DES placement. The PLATO trial demonstrated lower mortality rates with the use of Ticagrelor when compared to clopidogrel (9.8% vs. 11.7%, p<0.001) when treating patients with acute coronary syndrome. Given their pleiotropic benefits, statins are today the second most prescribed drug in the United States and often co-prescribed with Ticagrelor. FDA's post market surveillance of Ticagrelor use along with statins in post-myocardial infarction care is now revealing novel and serious adverse events. We present two cases of rhabdomyolysis and acute renal failure (ARF) which develop while the patients were on statins and Ticagrelor. Case 1: A 66-year-old female presented with bilateral thigh pain for 3 days. One month prior to presentation, she was managed for non-ST segment elevation myocardial infarction (NSTEMI) and had been started on aspirin, ticagrelor and simvastatin. Laboratory values revealed creatinine kinase (CK) level at 40,000 U/L and creatinine 3.2 mg/dL suggesting rhabdomyolysis and ARF. Case 2: A 63-year-old male presented with generalized body aches and fatigue for 4 days. He had sustained STEMI two months before and received two drug eluting stents (DES) and aspirin, ticagrelor and rosuvastatin had been initiated. CK was 380,000 U/L and creatinine 7.94 mg/dL suggesting rhabdomyolysis and ARF. Both patients presented with rhabdomyolysis and acute renal failure within weeks after ticagrelor and statin were commenced. A review of the literature indicated that 11 similar cases of ticagrelor-induced ARF and rhabdomyolysis had been reported. Ticagrelor competes with statins when metabolized by cytochrome P450 (CYP) 3A4 leading to statin retention, leading to major adverse effects like rhabdomyolysis and acute renal failure. Our review is intended to alert clinicians about this important drug interaction.

Keywords: acute renal failure; adenosine diphosphate (ADP) receptor P2Y12; cytochrome P450 (CYP) 3A4; drug interaction; rhabdomyolysis; statins; ticagrelor.

Figures

Figure 1.
Figure 1.
Graph demonstrating Creatinine Kinase values for Case 1
Figure 2.
Figure 2.
Graph demonstrating Creatinine Kinase values for Case 2

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References

    1. COMMIT (Clopidogrel and Metoprolol in Myocardial Infarction Trial) collaborative group. Addition of clopidogrel to aspirin in 45 852 patients with acute myocardial infarction: randomized placebo-controlled trial. The Lancet. 2005. November 5; 366(9497): 1607–21. - PubMed
    1. CURE (Clopidogrel in Unstable Angina to Prevent Recurrent Events Trial) Investigators. Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation. New England Journal of Medicine. 2001. August 16; 345(7): 494–502. - PubMed
    1. ames SK, Roe MT, Cannon CP, Cornel JH, Horrow J, Husted S, Katus H, Morais J, Steg PG, Storey RF, Stevens S, Wallentin L, Harrington RA. Ticagrelor versus clopidogrel in patients with acute coronary syndromes intended for non-invasive management: substudy from prospective randomised PLATelet inhibition and patient Outcomes (PLATO) trial, Br Med J, 2011, vol. 342 d3527. - PMC - PubMed
    1. Dobesh PP, Oestreich JH. Ticagrelor: pharmacokinetics, pharmacodynamics, clinical efficacy, and safety. Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy. 2014. October 1; 34(10): 1077–90. - PMC - PubMed
    1. Danielak D, Karaźniewicz-Łada M, Główka F. Ticagrelor in modern cardiology-an up-to-date review of most important aspects of ticagrelor pharmacotherapy. Expert opinion on pharmacotherapy. 2018. January 22; 19(2): 103–12. - PubMed

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