What is the treatment for Rhabdomyolysis?

Treatment of Rhabdomyolysis

Immediately initiate aggressive intravenous fluid resuscitation with isotonic saline (0.9% NaCl) targeting a urine output of 300 mL/hour, as this is the cornerstone of treatment and early initiation is critical to prevent acute kidney injury. 1, 2

Immediate Fluid Resuscitation

The single most important intervention is early and aggressive IV fluid administration. Delayed treatment significantly increases the risk of acute kidney injury and worse outcomes. 1, 2

Fluid volume requirements:

• Severe rhabdomyolysis (CK >15,000 IU/L): Administer >6L of fluid per day 1, 2
• Moderate rhabdomyolysis: Administer 3-6L per day 1, 2
• Target urine output: 300 mL/hour to facilitate myoglobin clearance and prevent renal tubular obstruction 2, 3

Monitor closely for fluid overload, particularly in patients with cardiac or renal compromise. 2

Discontinue Causative Agents

Immediately stop all potentially offending medications and supplements, including: 1

• Statins (most common medication cause, with incidence of 1.6 per 100,000 patient-years) 1
• Red yeast rice containing lovastatin 1
• Creatine monohydrate 1
• Wormwood oil, licorice, and Hydroxycut 1
• Any other prescription medications that may contribute 1

Cease the physical activity that triggered exertional rhabdomyolysis immediately. 2

Electrolyte Management and Monitoring

Monitor potassium levels closely every 6-12 hours in severe cases, as hyperkalemia can precipitate life-threatening cardiac arrhythmias and pulseless electrical activity where external defibrillation may be ineffective. 1, 2

Repeated bioassessment should include: 1

• Plasma myoglobin
• Creatine kinase (CK)
• Potassium
• Calcium, phosphorus, magnesium 1
• Metabolic acidosis assessment 2

Correct significant electrolyte abnormalities promptly, including hypocalcemia and hyperphosphatemia. 1, 2

Compartment Syndrome Surveillance

Maintain high suspicion for compartment syndrome, which can both cause and complicate rhabdomyolysis. 1, 2

Early signs: Pain, tension, paresthesia, and paresis 1, 2

Late signs: Pulselessness and pallor (indicating irreversible damage) 1, 2

Perform early fasciotomy when: 1, 2

• Compartment pressure exceeds 30 mmHg
• Differential pressure (diastolic BP – compartment pressure) is <30 mmHg

Adjunctive Therapies

After ensuring adequate volume expansion, a diuretic challenge with furosemide may help assess kidney function in select cases, as response to diuretics may predict successful recovery of kidney function. 2

Provide supplemental oxygen to address potential hypoxemia and support vital signs as needed. 2

Consider cooling measures if hyperthermia is present to protect against fulminating rhabdomyolysis. 2

Renal Replacement Therapy Indications

Initiate RRT when: 2

• CK remains persistently elevated despite 4 days of adequate hydration (indicates severe rhabdomyolysis with significant risk of irreversible kidney damage)
• Refractory hyperkalemia
• Severe metabolic acidosis
• Progressive acute kidney injury

Early initiation of RRT is associated with improved outcomes in severe cases. 2

Consider discontinuation of RRT when urine output recovers adequately (>100 mL/day). 2

Monitoring Parameters

Serial assessments should include: 2

• Hourly urine output via bladder catheterization (inadequate output <300 mL/hour suggests worsening kidney function)
• Serial creatinine and BUN measurements
• CK levels (continue IV fluids until CK <1,000 U/L) 4
• Continuous cardiac monitoring for arrhythmias 1

Critical Pitfalls to Avoid

Delaying fluid resuscitation is the most common error and is associated with higher risk of acute kidney injury and worse outcomes. 1, 2

Inadequate fluid volume (using <6L/day in severe cases) may fail to prevent renal complications. 2

Failure to monitor and correct hyperkalemia can lead to pulseless electrical activity and cardiac arrest. 2

Missing compartment syndrome, particularly in traumatic or severe exertional cases, can result in irreversible muscle and nerve damage. 2

Controversial Therapies

While sodium bicarbonate and mannitol have been historically used, they do not possess strong evidence for improved outcomes and should not delay aggressive fluid resuscitation. 3, 5 Sodium bicarbonate can be used for patients who are acidotic, and mannitol can be used for those whose urine output is not at goal, but these are adjunctive measures only. 4

Post-Acute Management

For patients requiring continued lipid management after statin-induced rhabdomyolysis, consider nonstatin therapies such as ezetimibe, PCSK9 inhibitors, or bempedoic acid. 1

If lipid management is needed, use hydrophilic statins (fluvastatin, pravastatin) as they have fewer metabolic interactions. 1