Rhabdomyolysis With Simvastatin and Nefazodone

Mr. A, a 72-year-old Hispanic man with recurrent depression, anxiety, insulin-dependent diabetes mellitus, hypertension, and hyperlipidemia, was referred for severe depression and anxiety. His medications upon his visit to the psychiatrist were paroxetine, lorazepam, mirtazapine, risperidone, zolpidem, insulin, metformin, and simvastatin. Multiple previous antidepressant trials of sufficient dose and duration had failed to relieve his symptoms. His only significant laboratory test abnormality was a glucose level of 40 mg/dl; no subsequent glucose levels had been found to be lower than 74 mg/dl. The psychiatrist discontinued paroxetine, mirtazapine, lorazepam, and risperidone and initiated nefazodone, 100 mg b.i.d., clonazepam, and trazodone. Four weeks later, the nefazodone dose was increased to 300 mg at bedtime.

Two weeks later, Mr. A was admitted to the medical service with a 3-day history of generalized weakness, a cough, a fever, and a provisional diagnosis of viral syndrome. After admission, the results of laboratory tests included a creatinine kinase level of 10,555 U/liter, an aspartate aminotransferase level of 72 U/liter, a lactose dehydrogenase level of 350 U/liter, and urine containing moderate blood, five to six red blood cells per high-power field, and one to two WBCs per high-power field. Mr. A’s blood urea nitrogen, creatinine, and alanine aminotransferase levels remained within normal limits; his serum myoglobin level was not tested. Nefazodone was discontinued, Mr. A was hydrated intravenously, and 2 days later he was discharged with a creatinine kinase level of 3869 U/liter. He was feeling less weak and afebrile. One week later, his weakness had nearly resolved (his creatinine kinase level was 261 U/liter). He has continued taking simvastatin and venlafaxine without complications.