Gareri Pietro, Segura-García Cristina, De Fazio Pasquale, De Fazio Salvatore, De Sarro Giovambattista
Department of Experimental and Clinical Medicine, Faculty of Medicine and Surgery, University Magna Graecia of Catanzaro, Clinical Pharmacology and Pharmacovigilance Unit, Mater Domini University Hospital, Catanzaro, Italy.
Ann Pharmacother. 2009 Jul;43(7):1354-9. doi: 10.1345/aph.1M063. Epub 2009 Jun 30.
To describe a case of sertraline-induced rhabdomyolysis in an elderly patient with dementia and comorbidities.
A 71-year-old woman visited a psychiatrist in September 2007 for her depressed mood. Her medical history included vascular dementia accompanied by depression, arterial hypertension, and heart failure, as well as cardiac pacemaker implantation several years earlier for severe bradyarrythmia. She had begun taking amisulpride 50 mg/day and diazepam 2 mg at bedtime 6 months prior to the psychiatrist appointment, with poor relief of her depressed mood. Her drug therapy also included nicergoline 30 mg/day, amlodipine 5 mg/day, aspirin 100 mg/day, candesartan 16 mg/day, and atenolol 25 mg/day. At this psychiatrist visit, sertraline 50 mg/day was added for her depression, and was continued after a geriatrician visit in October. Her mood improved significantly. On December 18, 2007, she was admitted to the cardiology unit to undergo a pacemaker replacement. Laboratory tests revealed creatine kinase (CK) 7952 IU/L, lactate dehydrogenase 1021 IU/L, myoglobin 2322 U/L, and aspartate aminotransferase 362 IU/L, resulting in a diagnosis of iatrogenic rhabdomyolysis. Amisulpride and sertraline were discontinued. On December 24, serum CK was 839 IU/L and myoglobin was 91 U/L and the patient was discharged. On January 22, laboratory tests showed normal values of CK, CK-MB, and myoglobin. Sertraline 50 mg/day was again prescribed for the patient's persistent depressed mood. Fifteen days later, blood tests showed CK 1327 IU/L and myoglobin 324 U/L; therefore, the drug was discontinued. CK and myoglobin levels normalized a week later. On April 2, escitalopram was started. At time of writing, there was no evidence of any increase in CK, myoglobin, or other markers of rhabdomyolysis.
The Naranjo probability scale indicated a probable relationship between sertraline treatment and the onset of rhabdomyolysis. No relationship between amisulpride and rhabdomyolysis was found. Furthermore, rechallenge with sertraline caused CK and myoglobin to again increase, which was reversed following a discontinuation of sertraline. The patient's other comorbidities and medications have not been suggested as possible interactions with sertraline that can cause rhabdomyolysis. Genetic defects of sertraline demethylation and/or Pglycoprotein binding or concurrent circumstances may explain the onset of rhabdomyolysis in this particular patient.
This patient's rhabdomyolysis was probably induced by sertraline therapy.
描述1例老年痴呆合并多种疾病患者因舍曲林诱发横纹肌溶解症的病例。
一名71岁女性于2007年9月因情绪低落就诊于精神科医生。她的病史包括血管性痴呆伴抑郁、动脉高血压、心力衰竭，以及数年前因严重心动过缓植入心脏起搏器。在预约精神科医生就诊前6个月，她开始每天服用50毫克氨磺必利和睡前服用2毫克地西泮，但抑郁情绪缓解不佳。她的药物治疗还包括每天30毫克尼麦角林、5毫克氨氯地平、100毫克阿司匹林、16毫克坎地沙坦和25毫克阿替洛尔。在此次精神科就诊时，加用了每天50毫克的舍曲林治疗抑郁，10月在老年病科医生会诊后继续用药。她的情绪有明显改善。2007年12月18日，她入住心内科接受起搏器更换。实验室检查显示肌酸激酶（CK）7952国际单位/升、乳酸脱氢酶1021国际单位/升、肌红蛋白2322微克/升和天门冬氨酸氨基转移酶362国际单位/升，诊断为医源性横纹肌溶解症。氨磺必利和舍曲林停用。12月24日，血清CK为839国际单位/升，肌红蛋白为91微克/升，患者出院。1月22日，实验室检查显示CK、CK-MB和肌红蛋白值正常。因患者持续情绪低落，再次开具每天50毫克的舍曲林。15天后，血液检查显示CK为1327国际单位/升，肌红蛋白为324微克/升；因此，停用该药。一周后CK和肌红蛋白水平恢复正常。4月2日，开始使用艾司西酞普兰。在撰写本文时，没有证据表明CK、肌红蛋白或其他横纹肌溶解标志物有任何升高。
Naranjo概率量表表明舍曲林治疗与横纹肌溶解症的发生之间可能存在关联。未发现氨磺必利与横纹肌溶解症之间存在关联。此外，再次使用舍曲林导致CK和肌红蛋白再次升高，停用舍曲林后恢复正常。未提示患者的其他合并症和药物与舍曲林之间可能存在导致横纹肌溶解症的相互作用。舍曲林去甲基化和/或P-糖蛋白结合的基因缺陷或并发情况可能解释了该特定患者横纹肌溶解症的发生。
该患者的横纹肌溶解症可能是由舍曲林治疗诱发的。
