Severe Rhabdomyolysis in an Elderly Patient With Diabetes and Vascular Disease: Interplay of Statin Therapy, Sodium-Glucose Cotransporter-2 (SGLT2) Inhibition, and Thiazide-Induced Hypokalemia

Rhabdomyolysis is a potentially life-threatening complication of drug therapy, particularly in elderly patients exposed to polypharmacy. Statins are a well-known cause, while thiazide-induced hypokalemia and volume depletion can further predispose to muscle injury. Sodium-glucose cotransporter-2 (SGLT2) inhibitors such as empagliflozin provide cardio-renal benefits but may potentiate statin toxicity and exacerbate dehydration and electrolyte imbalance, amplifying rhabdomyolysis risk. We report a 78-year-old woman with diabetes, hypertension, hyperlipidemia, and carotid artery disease, hypothyroidism, who developed severe rhabdomyolysis, acute kidney injury, and transaminitis while taking simvastatin, hydrochlorothiazide, and empagliflozin. She presented with generalized weakness, muscle soreness, and exertional dyspnea; labs showed a creatine kinase of 12,165 U/L, hypokalemia of 2.9 mmol/L, and elevated troponin. Management included intravenous hydration, electrolyte repletion, and discontinuation of offending agents, resulting in clinical and biochemical improvement. This case underscores the multifactorial etiology of rhabdomyolysis in elderly vascular patients, where dehydration and hypokalemia from thiazides and SGLT2 inhibitors may synergize with statin-induced myotoxicity, complicating evaluation when troponin is elevated without ischemic changes. Clinicians should maintain a high index of suspicion for rhabdomyolysis in patients with new muscle pain, weakness, or fatigue after starting empagliflozin, especially when combined with statins and diuretics, and prioritize early recognition, medication review, and hydration to prevent serious complications.