Therapeutic Group

Examples of Drugs

Mechanism of Risk

Reference

Statins

Atorvastatin, Simvastatin, Lovastatin, Rosuvastatin, Fluvastatin

HMG-CoA reductase inhibition → muscle cell damage; increased risk with CYP3A4-mediated interactions

[1-4,7,8]

Fibrates

Gemfibrozil (especially combined with statins)

Disruption of muscle metabolism and statin clearance

[1-4]

Antibiotics

Clarithromycin, Erythromycin, Daptomycin, Linezolid, Fluoroquinolones, Cephalosporins, Trimethoprim-sulfamethoxazole

CYP450 enzyme inhibition (especially CYP3A4) → increased concentration of myotoxic drugs

[8-12]

Immunosuppressants

Cyclosporin, Tacrolimus

CYP3A4 inhibition and mitochondrial toxicity

[3,13-16]

Antipsychotics

Haloperidol, Olanzapin, Risperidone

Catatonia, malignant hyperthermia, increased muscle tone, increased muscle activity

[1-4]

Antidepressants

SSRI (e.g. sertraline), tricyclic antidepressants

Serotonin syndrome, increased muscle tone, possible toxicity

[1-4]

Antiepileptics

Valproate, Phenytoin

Mitochondrial toxicity and direct muscle injury

[1-4]

Diuretics

Thiazides, furosemide

Dehydration and electrolyte imbalance predisposing to rhabdomyolysis

[1,4]

Antihypertensives

ACE-inhibitors, angiotensin receptor blockers

ARNI (rarely)

Hypotension, muscle hypoperfusion

[20]

Hipnotics/Sedatives

Benzodiazepines (e.g. alprazolam), barbiturates

Prolonged immobilization, CNS depression

[1,4]

Analgetics/Antipyretics

Paracetamol, salicylates

Mitochondrial toxicity, especially in overdose

[1,3,4]

Drugs and Toxins

Alcohol, cocaine, heroin, amphetamine, LSD

Vasoconstriction, hyperthermia, direct myotoxicity

[1,3,4]

Hormonal Disorders

Corticosteroids (long-term use)

Catabolic myopathy

[2,3]

Antiviral Drugs

Zidovudine

Mitochondrial dysfunction

[19]

Lipid-lowering agents (non-statins)

Ezetimibe (especially combined with statins)

Unclear mechanism: possible enhanced statin effect

[1,4,17,18]