<p>A Pharmacogenomic Dissection of a Rosuvastatin-Induced Rhabdomyolysis Case Evokes the Polygenic Nature of Adverse Drug Reactions</p>

Abstract

Rosuvastatin, is a widely-used statin for the treatment of hypercholesterolemia and the prevention of cardiovascular diseases. Although rosuvastatin is well tolerated, about 3/10.000 patients can suffer severe myopathy. Rhabdomyolysis is a severe medical condition that causes injury to the skeletal muscle, electrolyte imbalances, acute renal failure and extreme creatine kinase (CK) elevation. Little is known regarding the molecular involvement of rosuvastatin-induced rhabdomyolysis (RIR). It has been demonstrated that genomic variants associated with decreased enzymatic activity of proteins are important determinants in plasmatic and skeletal muscle distribution of rosuvastatin and its toxicity. Until now, no interactions of ticagrelor, ezetimibe and rosuvastatin have been described with the consideration of pharmacogenomics predisposition. The present report involves a whole-exome sequencing (WES), in a patient affected by rosuvastatin-induced rhabdomyolysis. A pharmacogenomic dissection was performed by analyzing a comprehensive subset of candidate genes (n=160) potentially related to RIR. The genes were selected according to their implication in drug metabolism or inherited myopathies. Using an innovative approach of bioinformatics analysis, considering rare and common variants, we identified 19 genomic variations potentially related to the pharmacokinetic/pharmacodynamic modifications of rosuvastatin, ezetimibe and ticagrelor. The affected genes are involved in Phase I metabolism (CYP2C19, CYP2E1, CYP1A1, CYP2D6 and CYP2C9), Phase II metabolism (UGT2B15 and UGT2B7), influx transportation (SLCO1B3 and SLCO2B1), efflux transportation (ABCG8, ABCB11, ABCC4 and ABCB1), drug targeting (NPC1L1) and inherited myopathy etiology (OBSCN). We report three rare, potentially pathogenic molecular variants in CYP2C19, NPC1L1 and OBSCN genes. Pharmacogenetic analysis indicated that the patient was a carrier of inactivating alleles in several pharmacogenes involved in drug toxicity. The whole-exome sequencing and bioinformatics analysis presented here represents an innovative way to identify genomic variants contributing with RIR´s origin and evokes the polygenic nature of adverse drug reactions.

Rhabdomyolysis during concomitant ticagrelor and rosuvastatin: A breast cancer resistance protein‐mediated drug interaction?

“…In the literature, we found a total of 11 reported cases of rhabdomyolysis during concomitant treatment with ticagrelor and rosuvastatin (Table S4). 2–12 The patients (7 female, 4 male) were aged 49–87 years. The daily dose of rosuvastatin was 20–40 mg, and daily dose of ticagrelor 90–180 mg. Time to rhabdomyolysis onset from the start of concomitant medication was 2 weeks to 8 months (median 1.75 months).…”

“…In the literature, we found a total of 11 reported cases of rhabdomyolysis during concomitant treatment with ticagrelor and rosuvastatin (Table S4). [2][3][4][5][6][7][8][9][10][11][12] The patients (7 female, 4 male) were aged 49-87 years.…”

“…The treatment is usually well tolerated. However, clinicians have reported multiple cases of rhabdomyolysis during concomitant use of rosuvastatin and ticagrelor, [2][3][4][5][6][7][8][9][10][11][12] leading to a growing suspicion of an underlying drug-drug interaction. Three cases were recently identified and are described in this article for the first time.…”

Ticagrelor Increases Exposure to the Breast Cancer Resistance Protein Substrate Rosuvastatin

“…Although usually well‐tolerated, rosuvastatin can cause muscle symptoms of varying severity, especially at higher doses 1 . Previously published case reports have suggested that concomitant use of rosuvastatin and the platelet‐inhibitor ticagrelor may have led to severe, even fatal, cases of rosuvastatin‐induced rhabdomyolysis 2–13 . Because the risk of rosuvastatin‐induced myotoxicity is concentration‐dependent, the rhabdomyolysis cases suggest a potential pharmacokinetic drug–drug interaction between ticagrelor and rosuvastatin.…”

“…led to severe, even fatal, cases of rosuvastatin-induced rhabdomyolysis. [2][3][4][5][6][7][8][9][10][11][12][13] Because the risk of rosuvastatin-induced myotoxicity is concentration-dependent, the rhabdomyolysis cases suggest a potential pharmacokinetic drug-drug interaction between ticagrelor and rosuvastatin.…”