rhabdomyolysis
11 interactions related to rhabdomyolysis
simvastatin + red yeast rice
Red yeast rice contains monacolin K, which is chemically identical to the prescription statin lovastatin. Adding it to simvastatin stacks two statins with similar mechanisms and metabolism, sharply increasing the risk of myopathy, rhabdomyolysis, and liver injury.
atorvastatin + niacin
Combining high-dose niacin (1-2 g/day, typically extended-release) with atorvastatin or other statins increases the risk of myopathy and rhabdomyolysis. The HPS2-THRIVE trial documented a fourfold excess of myopathy when extended-release niacin was added to simvastatin-based therapy, and the AIM-HIGH trial showed no cardiovascular benefit from this combination.
lovastatin + grapefruit
Grapefruit juice blocks intestinal CYP3A4, dramatically increasing lovastatin and lovastatin acid exposure. A controlled study showed lovastatin Cmax rose ~12-fold and AUC ~15-fold after high-dose grapefruit juice, sharply raising the risk of myopathy and rhabdomyolysis.
simvastatin + berberine
Simvastatin is extensively metabolized by CYP3A4, and berberine inhibits CYP3A4 in vitro, which can raise simvastatin levels and increase the risk of myopathy and rhabdomyolysis. The interaction is bidirectional in some models (induction is also possible), making net effect unpredictable.
atorvastatin + red yeast rice
Red yeast rice naturally contains monacolin K, which is chemically identical to the prescription statin lovastatin. Combining it with atorvastatin effectively stacks two statins, sharply increasing the risk of myopathy, rhabdomyolysis, and liver injury.
seville orange + atorvastatin
Seville (bitter) orange contains the same furanocoumarins as grapefruit, including bergamottin and 6',7'-dihydroxybergamottin, which irreversibly inhibit intestinal CYP3A4. A landmark crossover study showed Seville orange juice raised felodipine AUC by 76%, comparable to grapefruit, and atorvastatin shares the same CYP3A4 metabolic pathway, raising the risk of statin-induced myopathy.
pomegranate + statins
Pomegranate juice inhibits intestinal CYP3A4, the main enzyme that metabolizes simvastatin, atorvastatin, and lovastatin. A published case report links pomegranate juice consumption to rhabdomyolysis in a patient stable on rosuvastatin, and the same enzyme inhibition can raise the systemic exposure and muscle toxicity risk of CYP3A4-metabolized statins.
alcohol + statins
Statins and alcohol are both metabolized by the liver and can independently raise transaminases; combined heavy use increases the risk of hepatotoxicity and, in some cases, myopathy or rhabdomyolysis. Atorvastatin plasma levels rise sharply in patients with alcoholic liver disease.
cbd + simvastatin
Simvastatin is heavily dependent on CYP3A4 for first-pass and systemic clearance, and CBD inhibits CYP3A4. Co-administration is expected to raise simvastatin and active-metabolite exposure, increasing the risk of muscle pain, transaminase elevation, and rare rhabdomyolysis.
pomelo + simvastatin
Pomelo (Citrus maxima) contains furanocoumarins that irreversibly inhibit intestinal CYP3A4, the enzyme that metabolizes simvastatin during first-pass absorption. With CYP3A4 disabled, simvastatin plasma concentrations rise substantially, increasing the risk of myopathy and rhabdomyolysis.
atorvastatin + berberine
Berberine inhibits CYP3A4 in vitro and can raise plasma levels of CYP3A4 substrates, including atorvastatin, which may increase the risk of muscle pain, liver enzyme elevation, and rhabdomyolysis. The interaction direction is complex — some animal data also show induction — but co-use is unpredictable.