DRUG INDUCED LIVER INJURIES BY TICAGRELORSTATINS INTERACTION: A CASE REPORT

Abstract

Background: The anti-aggregant therapy with aspirin and inhibitor of P2Y12 platelets receptor for ADP, such as ticagrelor, can be used to prevent atherothrombotic events in patients with coronaric acute syndrome. Statins are also recommended in these patients even if the safety profile is burdened by the risk of drug interaction (CYP 3A4 inhibition by ticagrelor). Here, we report a case of acute rabdomiolysis and hepatotoxicity in a woman with a recent myocardial infarction treated with ticagrelor 90 mg twice daily, aspirin 100 mg daily, atorvastatina 40 mg once daily. Methods: We report a case of 68 old Caucasian woman with a diagnosis of myocardial infarction and coronary percutaneous stenting treated with ticagrelor and statins, complaining since the first month after discharging of general illness, asthenia, nausea, myalgia, itching and epistaxis. For the accentuation of these symptoms, in the following month she was admitted to our Division of Internal Medicine. Results: At admission, laboratory showed an eleveted value of CPK (100 upper normal limits), eleveted cytolytic and cholestatic values (AST/ALT 45-30 u.n.l, ggt 10 u.n.l, AP 2 u.n.l, bilirubin tot/ 4, 8 mg/dl), creatinine clearance was 37, 3 mL/min/1, 73 m2. No history of alcohol or drug abuse was reported; non-organ specific autoantibody (ANA, SMA, LKM) and viral serology (HAV, HBV, HCV, CMV, HSV) were negative. According consensus criteria for Drug Induced Liver Injury (DILI) patient was diagnosed as suffering from a hepatocellular liver injury. RUCAM score was calculated as 11 (highly probable). Assuming an episode of interaction due to ticagrelor and atorvatastin, we withdrawn immediately atorvastatin and continued ticagrelor with ASA. There was a clinical and biochemical improvement, with decrease of creatinkinase and aminotransferases till normal values within 15 days. Intravenous fluids and albumin were administered to avoid acute kidney failure. Discussion and Conclusions: Drug-drug interaction between ticagrelor and atorvastatin caused certainly the development of muscle and liver injuries. Physician should be informed of the possibility that the ticagrelor/statin association even useful to prevent atherothrombotic events in patients with coronaric acute syndrome could be cause muscle, liver and kidney injuries