Case report: Rhabdomyolysis and kidney injury in a statin-treated hypothyroid patient-kill two birds with one stone

[helvella]

This case report has a good side: the patient did get diagnosed and treated. But that only follows the dreadful treatment - missing cause of high cholesterol, took statins, rhabdomyolysis, kidney injury.

Claims to have been reversed. (I'd like to see the patient's opinion!) But questionable whether even one month of such suffering can be dismissed, pretty much, as one of those things.

It is obviously far more sensible to run at least TSH/FT4/FT3 before prescribing statins. Indeed, in my view, that should be mandatory.

The case report just comes across as too gung ho. Too "see how amazing we are". Even the title overclaims.

Case report: Rhabdomyolysis and kidney injury in a statin-treated hypothyroid patient-kill two birds with one stone.

Chiang WF 1, 2 , Chan JS 1, 2 , Hsiao PJ 1, 2 , Lin SH 2

Frontiers in Medicine, 10 Nov 2022, 9:1046330

DOI: 10.3389/fmed.2022.1046330 PMID: 36438056 PMCID: PMC9684604Share this article

Abstract

Statin treatment for hypercholesterolemia may cause reversible rhabdomyolysis and acute kidney injury in susceptible patients. However, persistent rhabdomyolysis and acute kidney injury following discontinuation of statins require careful evaluation of the underlying causes to avoid missing a curable disease. We describe a 50-year-old woman with hypercholesterolemia [total cholesterol 345 mg/dl, low-density lipoprotein cholesterol (LDL-C) 266 mg/dL] on atorvastatin therapy (40 mg daily) for 1 month that presented with myalgia and muscle weakness. Relevant laboratory studies revealed persistent higher hypercholesterolemia with total cholesterol (312 mg/dL), high creatine kinase (CK) (5,178 U/L), and high creatinine levels (1.5 mg/dL) without dysmorphic red blood cells and proteinuria. Despite the cessation of statin therapy, serum CK level increased to 9,594 U/L, and creatinine remained at 1.5 mg/dL. A thorough work-up to assess potential underlying causes indicated low T3 and free T4 and high thyroid-stimulating hormone (TSH) levels, consistent with hypothyroidism. With aggressive thyroxine replacement for 1 month, all of the clinical features, along with elevated serum CK and creatinine levels, were completely resolved. This case highlights the fact that hypothyroidism must be kept in mind as a potential cause of concomitant myopathy and kidney injury, especially in patients with statin-resistant hypercholesterolemia.

europepmc.org/article/MED/3...

[greygoose]

If I ruled the world, people would automatically be tested for thyroid when they went to the doctor for anything! Anything and everything. That may sound expensive, but if the people found to be hypo were treated correctly, they'd end up saving millions.

[JGBH in reply to greygoose]

I agrée but this goes for many other health conditions, not just hypothyroidism.

[greygoose in reply to JGBH]

Well, yes, but given how hypothyroidism can mimic so many other conditions, it seems sensible to rule that out first. Then go on to look at other conditions.

[shaws in reply to greygoose]

My TSH was 100 and GP still told me that I had no problems!!! I was feeling very unwell.

[greygoose in reply to shaws]

Unbelievable, isn't it!

[shaws in reply to greygoose]

Yes it is unbelievable and the doctors must have been in their late 50's. So I assume that many of their patients must have been misdiagnosed or undiagnosed.

[greygoose in reply to shaws]

Doctors are responsible for so much suffering in the world when it comes to thyroid.

[jgelliss in reply to greygoose]

Totally agree GG with you. Well said. However if ones thyroid labs are within range that is inconclusive according to Dr's. It's a very big problem.

[Kowbie in reply to greygoose]

Totally agree

[helvella]

I'd like to know what they mean by "aggressive" thyroxine replacement?

And how they can be so sure everything in the garden is rosy in just one month of treatment. Which doesn't even cover a single follow up test at six to eight weeks!

[radd in reply to helvella]

helvella,

Yes, 'aggressive thyroxine replacement' could sound very, errrr ..... damaging!? They make sound like a quick high intensity fix 😳

[Poniesrfun in reply to helvella]

Looking at the full article, the "improved" kidney and liver indices are shown three months later. But I'm surprised they didn't use IV T3 and/or T4. (The treatment says 200mg thyroxine/day for one month but I didn't see how or what was continued.)

There's an interesting table further on in the full article comparing Rhabdo from statins vs hypothyroidism further on. So if someone is hypo and has symptoms, how many docs think to run CK, renal and liver tests? Also, the subjects hypothyroidism was pretty severe; she did have antibodies. So was this chronic and worsening on its own or was the acute hypo triggered by the statin? In the US she would likely be in ICU with IV T3/T4 instead of oral meds, at least initially. And they don't show her lab levels during hospitalization or on discharge (leaving me wondering if they hadn't improved enough yet on oral therapy to be able to prove their point).

Patti in AZ

[shaws in reply to helvella]

whoever made the above statement must have a condition called:- 'hypothyroidism." !!!

[jgelliss]

Thank you Helvella for bring this post to the for front. Most people with very high cholesterol might be bettered served if the would run labs with all the thyroid markers. The only problem with that is that if the labs come back within range Dr will call that the thyroids are not the cause. In addition I feel that Dr rush to put patients on statins when in reality we need cholesterol to make our hormones. It's a big problem how Dr's treatments work these days.

[bagsypartime]

I'm on 80 atorvastatin, am hypothyroid 100 levy, and blood tests say something wrong with my kidneys.

As far as I know no bad reaction to any drugs, ie, joint pain etc.Is this saying the statin could be affecting my kidney?Is it saying that statins effect hypothyroid people in a different way?

[helvella in reply to bagsypartime]

It's important not to take a single case study and blindly apply to everyone.

But, yes, atorvastatin can affect the kidneys. And, yes, this does seem related to hypothyroidism.

However, I suspect a lot of doctors would point out that thyroid hormones, in adequate dose, effectively mean you are not hypothyroid! In their view.

My view is that it would appear entirely reasonable to stop the statin, at least for a while, and see whether your kidney problems start to resolve. Ideally, this would be properly monitored with tests before and after a few weeks.

[humanbean in reply to helvella]

However, I suspect a lot of doctors would point out that thyroid hormones, in adequate dose, effectively mean you are not hypothyroid! In their view.

I think an obvious retort to that would be that the thyroid produces multiple hormones and yet treatment for hypothyroidism usually only replaces one of them.

Whatever happened to calcitonin? Why doesn't it get mentioned any more?

And doctors pretend that they don't personally have T3 flowing through their veins and arteries, tell some patients it's dangerous, it's a waste product when it is the actual active thyroid hormone required by the human body.

[SlowDragon Administrator in reply to bagsypartime]

100mcg levothyroxine is not a high dose levothyroxine, especially for a chap……what are your most recent thyroid and vitamin results

ALWAYS test thyroid levels early morning, ideally just before 9am, only drink water between waking and test and last dose levothyroxine 24 hours before test

Please new post of your own with thyroid and vitamin results

For full Thyroid evaluation you need TSH, FT4 and FT3 tested

Also both TPO and TG thyroid antibodies tested at least once

Very important to test vitamin D, folate, ferritin and B12 at least once year minimum

[bagsypartime in reply to SlowDragon]

I know you are right slow dragon but as i don't have any problems (apart from a blood test saying low iron and bad kidney) i'm too lazy.

Say i had a private test and found something i don't think the doc would take my word anyway.

I use supplements and hope for the best

[radd in reply to bagsypartime]

bagsypartime,

Being hypo can invite that loss of drive and natural sense to preserve oneself. SD is right and if your thyroid hormones levels are low or not working properly through other insufficiencies, things will only get worse 🤗

Edit - You could point your doctor in the direction of the NHS website that cautions statins in hypo people but I also think you need to do your own research regarding the kidney issues and look after yourself because a GP won't always.

[SlowDragon Administrator in reply to bagsypartime]

Your choice

Personally I would test annually myself and at least maintain OPTIMAL vitamin levels

Men are rarely low in iron

Are you vegetarian or vegan

Low GFR (kidney function) linked to low Ft3

Taking Statins with hypothyroidism more likely to cause muscle damage

nhs.uk/conditions/statins/c...

If you have an underactive thyroid (hypothyroidism), treatment may be delayed until this problem is treated. This is because having an underactive thyroid can lead to an increased cholesterol level, and treating hypothyroidism may cause your cholesterol level to decrease, without the need for statins. Statins are also more likely to cause muscle damage in people with an underactive thyroid.

Being under medicated for thyroid can cause heart issues too

Very important to test Ft4 and Ft3 to see how well you convert

Heart and brain need good levels of T3

TSH should be under 2 as an absolute maximum when on levothyroxine

gponline.com/endocrinology-...

Subclinical thyroid dysfunction

A recent meta-analysis revealed a 50 per cent increase in the risk of coronary artery disease at baseline and a 20 per cent increase at follow-up in patients with subclinical hypothyroidism.

[userotc in reply to bagsypartime]

Well even NHS report that one of the more serious side effects of your statin maybe kidney damage nhs.uk/medicines/atorvastat...

[helvella in reply to bagsypartime]

You might care to view the Yellow Card report for atorvastatin:

info.mhra.gov.uk/drug-analy...

Renal failure and impairment 140 (adverse reactions) 7 (deaths)

[humanbean in reply to bagsypartime]

Read the section on this page about statins entitled "People at an increased risk of side effects".

nhs.uk/conditions/statins/c...

I refused to take statins when I was told I needed them. I have several health problems, not just hypothyroidism, and getting treatment has been difficult or impossible for so many of them.

I'd rather forego any claimed benefits of statins to make sure I don't get side effects. If I got any of the side effects I wouldn't expect to be believed anyway, so why bother.

Statins increase the risk of dementia, type 2 diabetes, muscle pain, and several other things. Not all of these side effects are guaranteed to go away if statins are stopped. So, no. A statin will never pass my lips voluntarily.

Some links on statins that are worth reading :

drmalcolmkendrick.org/2012/...

In the above link pay particular attention to BOTH graphs.

spacedoc.com/articles/50-fa...

In the above link my favourite fact in the list is number 17.

diabetes.co.uk/forum/thread...

[Poniesrfun in reply to bagsypartime]

According to the chart in Table 2 in the full article, for hypothyroidism:

Rhabdomyolysis - Not uncommon (but only 1 case/10,000 person-years for statins)

Renal function - Often reduced (reduced renal blood flow) (but Usually normal for statins)

So they are implying that it's the hypothyroidism, not the statins causing these signs. But they must actually test for Rhabdo (by testing CK) and FT4/FT3. Despite the literature showing that appropriate FT4/FT3 levels improve lipids and glucose, many doctors still deny that.

I think the Table 2 makes sense. If muscle cells don't have adequate T3 to complete the energy cycle, I believe that would contribute to the Rhabdomyolysis which clogs the kidney tubules. The normal response to Rhabdo is lots of fluids to keep the kidneys viable while determining the cause. Common in endurance athletes which has me thinking that depletion of T3 during intense exercise could be a contributor. Caveat - I am not a biochemist. (Taking T3 is almost as popular as steroids for some athletes. This abuse can lead to reluctance to prescribe it for thyroid patients who need it).

Patti in AZ

[bagsypartime in reply to Poniesrfun]

Humanbean points out that though i have been diagnosed with hypothyroidism as i am taking Levo i do not have it.(effectively).

And the t3, this is so obtuse that doctors can't understand it so it's hardly likely we are going to make sense of it.

Not saying you are wrong but the science is tenuous.

[bagsypartime]

I don't want to be the person actually sticking up for statins.However having followed one of the links the idea seems to be that you get myopathy -muscle damage- and this leads to a kidney issue.Not the other way round.I had a blood test in may.

ahem 118

white 7.5

plate302

h-ocit39%

red 4.54

mean corp vol 86

mean cor team 26so

neutro4.66

lymph 2.00

mono .56

eosinophil 0.19

baso0.07

hba1c 40

serum3.7

sodium139

potas4.6

creatine 130.......ckd-epi 1.73

protein 76

cacium2.46

albumin 44

adjusted calc 2.46

alk phosph 109

bilirubin 9

alt13

cholesterol 3.1

tryglic 1.5

hdl.9

ldl1.5

ratio 3.4

non hdl 2.2

aki warning 0

84kg 176cm

[bagsypartime]

The other thing about Statins are that they are a great story and you'd have to be soulless not to root for them.Researxhers won the nobel prize when they found a link between heart disease and cholesterol.Lower that and we would have no more heart disease.The prediction was there would be no heart disease after the year 2000.Most people would agree that is a pretty great and inspiring idea.

They had to find a drug to lower this cholesterol and the race was on to end heart disease.The man who cracked it was a fan of louse pasteur and penicillin except that this guy also had an interest in fungus that have cholesterol as their life force much as we have blood and oxygen and plants have photosynthesis.A fungus can attack other fungus and protect it's territory by disrupting this life force.He found the chemical they use and that's what statins are, fungus derived.

They are claimed as a big medical success story, and they are certainly a financial one.People at high risk such as myself do seem to benefit from them.However the wider population seem to be given them once they hit forty and the evidence for this is less convincing.

But as i have said they are a great story.

[greygoose in reply to bagsypartime]

Cinderella is a great story. Doesn't mean it has any basis in fact.

I could go on about statins and cholesterol for hours, but I don't want to bore you as you obviously have great faith in statins= good and cholesterol = bad, but I would just point out that my 'boyfriend' (rediculous to call him that at our age!) took statins and ended up with prostate cancer. Why? Because the adrenals need cholesterol to make sex hormones. Low cholesterol means low testosterone. Low testosterone means lack of protection against certain cancers. And that's just one aspect of the dangers of statins. Do you get your testosterone tested regularly?

[helvella in reply to bagsypartime]

If you want to carry on discussing, I suggest you create a brand new post.

Also, the laboratory reference intervals for most tests vary by lab. For people to understand your results, we do need you to tell us what they are!

[BeeOrchids]

I was prescribed statins following a doctor's review where my cholesterol level was 8.3. I had got the level down from 9.8 through diet and taking more exercise in three months but that wasn't good enough for the GP. I lasted two weeks taking them before ending up in A&E with breathing difficulties, a swollen throat and feeling of something being caught in it when I tried to swallow food or drink, muscle pains, nightmares and feeling utterly dreadful. I was told after extensive testing that it was side effects of the statins and I should definitely stop taking them and see my GP. I rang the following day and was told a phone appointment had been made for the same day. 30 minutes later it was cancelled and I was told to wait for further contact to be made. That will be three weeks ago on Tuesday and I'm not holding my breath on anyone bothering to contact me.

[helvella in reply to BeeOrchids]

Terrible treatment - in several senses.

I do suggest you put in your own Yellow Card report. There is a pinned post to help!

[BeeOrchids in reply to helvella]

Yes, have done that. Did a week after the A&E visit. The pharmacist in my local branch of Boots was more helpful and interested. She was the one who reminded me about the Yellow Card reporting system.

[helvella in reply to BeeOrchids]

Thanks - every one helps!

[BB001]

This supports my analysis that my creatinine rises as my fT3 level falls. I have decided to use creatinine as a proxy to judge my fT3 levels for when the lab doesn't do the requested fT3 test.

[helvella in reply to BB001]

How do you measure the creatinine?

Just had a fleeting thought that some urine dipsticks include creatinine and wondering if they could at least identify the more extreme raised creatinine levels?

[BB001 in reply to helvella]

My creatinine is measured on my GP blood tests. It's the 'U&E Creatinine' box that ticked to get it.

[helvella in reply to BB001]

Right-ho! Thanks.

What sort of numbers do you see?

[BB001 in reply to helvella]

I'm currently on my phone as usual and they're stored on my computer. I won't get chance to look them up for a couple of days. Feel free to remind me.

[helvella in reply to BB001]

Thanks! There is no hurry, of course.

[Funkycherry]

This is interesting. I'm currently being investigated for high creatinine and low eGFR. Can anyone point me in the direction of information regarding the link to Hypothyroidism?

I've been diagnosed hypo and on Levothyroxine for around 10yrs.

[helvella in reply to Funkycherry]

Calling out to BB001

[BB001 in reply to helvella]

Thank you for tagging me, else I probably wouldn't have seen it.

[BB001 in reply to Funkycherry]

I found this research interesting and bookmarked it. sciencedirect.com/science/a...