A rare rosuvastatin–clarithromycin interaction presenting with acute liver injury and delayed rhabdomyolysis

Abstract: Rosuvastatin, a hydrophilic statin, is generally considered to have a low risk of clinically significant interactions with macrolide antibiotics, and concurrent use with clarithromycin is not contraindicated according to NHS Specialist Pharmacy Service guidance. However, rare cases of severe toxicity have been reported, particularly in the elderly or critically ill patients. A 69-year-old male, with a past medical history of ischemic heart disease developed marked transaminase elevation followed by severe rhabdomyolysis after receiving high-dose rosuvastatin concurrently with clarithromycin for a lower respiratory tract infection. Withdrawal of both agents, along with supportive treatment with intravenous N-acetylcysteine and ursodeoxycholic acid led to a rapid biochemical improvement. The patient subsequently died due to refractory shock related to his critical illness, and death was not directly attributed to the suspected drug–drug interaction. This case highlights a rare but clinically important interaction between rosuvastatin and macrolides that may be under-recognized, particularly in the elderly or critically ill patients.