What is the treatment for Rhabdomyolysis (muscle breakdown disease)?

Treatment of Rhabdomyolysis

Aggressive intravenous fluid resuscitation is the cornerstone of treatment for rhabdomyolysis, with a goal urine output of 300 mL/hour to prevent acute kidney injury. 1, 2

Diagnosis and Assessment

• Rhabdomyolysis is characterized by the breakdown of skeletal muscle with release of intracellular contents into circulation, often presenting with muscle pain, weakness, and dark urine 3
• Laboratory diagnosis requires creatine kinase (CK) levels at least 10 times the upper limit of normal and assessment of myoglobinuria 4
• Comprehensive laboratory workup should include:
  • Electrolytes (particularly potassium, calcium, phosphorus, and magnesium) 1
  • Renal function tests to monitor for acute kidney injury 2
  • Repeated bioassessment of plasma myoglobin, CK, and potassium 1

Treatment Algorithm

Immediate Management

• Begin immediate, aggressive intravenous fluid resuscitation:
  • For severe rhabdomyolysis (CK >15,000 IU/L): >6L of fluid per day 1, 2
  • For moderate cases: 3-6L of fluid per day 1, 2
  • Goal: maintain urine output of at least 300 mL/hour 4, 3

Fluid Management

• Use isotonic crystalloid solutions (normal saline) for initial resuscitation 3
• Early initiation of fluid resuscitation is critical, as delayed treatment increases risk of acute kidney injury 1
• Continue IV fluids until CK levels decrease to less than 1,000 U/L 4

Electrolyte Management

• Monitor and correct significant electrolyte abnormalities, particularly hyperkalemia which can lead to cardiac arrhythmias 1, 2
• Obtain serial ECGs to evaluate for cardiac complications of hyperkalemia 5
• Address hypocalcemia if symptomatic 3

Compartment Syndrome Management

• Monitor for compartment syndrome, a serious complication of rhabdomyolysis 1
• Early signs include pain, tension, paresthesia, and paresis; late signs include pulselessness and pallor 1
• Consider fasciotomy when:
  • Compartment pressure exceeds 30 mmHg 1, 2
  • Differential pressure (diastolic blood pressure – compartment pressure) is <30 mmHg 1

Special Considerations

Renal Protection

• Maintain adequate hydration throughout treatment 1
• Consider sodium bicarbonate for patients who are acidotic 4
• Consider mannitol for patients whose urine output is not at goal despite adequate fluid resuscitation 4
• Renal replacement therapy may be necessary for severe cases with refractory hyperkalemia or severe acidosis 3

Medication Considerations

• Avoid medications that can exacerbate rhabdomyolysis, particularly succinylcholine 1
• Discontinue any causative medications, particularly statins if they are the suspected cause 2
• For perioperative patients, consider discontinuation of dietary supplements associated with higher risk for myositis or rhabdomyolysis 1

Prevention of Complications

• Monitor for and address complications:
  • Acute kidney injury (most significant complication) 4
  • Severe electrolyte abnormalities 1
  • Compartment syndrome 1, 2
  • Disseminated intravascular coagulation 4

Cause-Specific Management

• For exertional rhabdomyolysis: proper calibration of training and conditioning, especially during transition periods 2
• For medication-induced rhabdomyolysis: identify vulnerable patients before starting high-risk medications 2
• For infectious causes: appropriate antimicrobial therapy based on suspected pathogen 2
• For immune checkpoint inhibitor-induced myositis with rash: consider high-dose corticosteroids 2