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

Treatment of Rhabdomyolysis

Aggressive intravenous fluid resuscitation is the cornerstone of rhabdomyolysis treatment, with immediate initiation of >6L per day for severe cases (CK >15,000 IU/L) and 3-6L per day for moderate cases, targeting a urine output of 300 mL/hour to prevent acute kidney injury. 1, 2, 3

Immediate Management Algorithm

Step 1: Discontinue Offending Agents

• Immediately stop any causative medications, particularly statins, which cause rhabdomyolysis at a rate of 1.6 per 100,000 patient-years 1
• Discontinue dietary supplements including red yeast rice (contains lovastatin), creatine monohydrate, wormwood oil, licorice, and Hydroxycut 1
• Avoid succinylcholine in the perioperative setting as it can exacerbate rhabdomyolysis 1

Step 2: Aggressive Fluid Resuscitation

• Begin isotonic saline (0.9% NaCl) immediately - delayed fluid resuscitation significantly increases acute kidney injury risk 1, 2, 4
• For severe rhabdomyolysis (CK >15,000 IU/L): administer >6L of IV fluids daily 1, 2
• For moderate rhabdomyolysis: administer 3-6L of IV fluids daily 1, 2
• Target urine output of 300 mL/hour to ensure adequate kidney perfusion 2, 3
• Early vigorous fluid resuscitation (≥12L daily in some protocols) has reduced mortality from nearly 100% to <20% in crush syndrome over the past 70 years 4

Critical pitfall: Do not use diuretics as primary treatment - they may increase acute kidney injury risk unless adequate volume resuscitation has been achieved first 2. Mannitol may only benefit patients with CK >30,000 U/L and is contraindicated in oligoanuria 2.

Step 3: Monitor and Correct Electrolyte Abnormalities

• Check potassium levels immediately and obtain ECG - hyperkalemia causes life-threatening cardiac arrhythmias 1, 2
• Perform repeated measurements of plasma myoglobin, CK, and potassium 1, 2
• Monitor calcium, phosphorus, and magnesium levels 1
• Assess for metabolic acidosis with arterial blood gas 1
• Use bladder catheterization to monitor hourly urine output 2

Step 4: Assess for Compartment Syndrome

• Early signs: pain, tension, paresthesia, and paresis 1, 5
• Late signs (often irreversible): pulselessness and pallor 1, 5
• Perform early fasciotomy when compartment pressure exceeds 30 mmHg or when differential pressure (diastolic BP - compartment pressure) is <30 mmHg 1, 5

Laboratory Workup

• Complete electrolyte panel (potassium, calcium, phosphorus, magnesium) 1
• Creatine kinase (diagnosis requires CK >5 times upper limit of normal) 3
• Creatinine and BUN for renal function 1
• Urinalysis showing brown color, cloudiness, and positive for blood without RBCs indicates myoglobinuria 1
• Liver function tests to assess hepatic involvement 1
• Coagulation studies to evaluate for disseminated intravascular coagulation 1

Renal Replacement Therapy

• Consider dialysis for myoglobinuric renal failure on a case-by-case basis 1, 3
• Indications include severe oliguria despite adequate fluid resuscitation, refractory hyperkalemia, or severe metabolic acidosis 6

Post-Acute Management for Statin-Induced Cases

• Do not rechallenge with the same statin 1
• Consider nonstatin therapies including ezetimibe, PCSK9 inhibitors, or bempedoic acid for continued lipid management 1
• If lipid management is essential, use hydrophilic statins (fluvastatin, pravastatin) as they have fewer metabolic interactions 1
• Refer to neurologist specializing in neuromuscular disorders if autoimmune myopathy is suspected 5

Special Populations

Exertional Rhabdomyolysis

• Properly calibrate training and conditioning sessions, especially during transition periods (returning after injury) 1
• Maintain adequate hydration throughout exercise 1

Drug Interactions

• Avoid combining statins with ciclosporin, macrolides, azole antifungals, calcium antagonists, protease inhibitors, or fibrates 7
• Use hydrophilic statins if concurrent medications metabolized by CYP3A4 are necessary 1

Admission Criteria

• Hospitalize patients with: immunocompromised state, severe pain requiring management, mental confusion, pulmonary infiltrates, abnormal spinal fluid findings, or organ failure 1
• Most patients with rhabdomyolysis require admission, though select cases with mild elevation and adequate oral hydration may be discharged with close follow-up 3

Key evidence note: Bicarbonate and mannitol do not possess strong evidence for improved outcomes in rhabdomyolysis 3. The single most important intervention remains early, aggressive isotonic fluid resuscitation 4.