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Colchicine Triple Interaction Rhabdomyolysis — ESENeph MCQ

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HardAcute Kidney InjuryColchicine Triple Interaction RhabdomyolysisESENeph

A 45-year-old man with CKD G3b is prescribed Colchicine 0.5 mg BD for acute gout. He is also on Atorvastatin 40 mg and Clarithromycin (for a chest infection). Three days later he develops severe diarrhoea, myalgia, and weakness. CK is 12000 U/L. What has occurred?

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Correct answer: E — Colchicine toxicity potentiated by CYP3A4 inhibition from Clarithromycin AND increased myotoxicity from statin-Colchicine interaction – triple interaction causing rhabdomyolysis

Colchicine is metabolised by CYP3A4 and P-glycoprotein. Clarithromycin is a potent CYP3A4 inhibitor, dramatically increasing Colchicine levels. Concurrent statin use increases the risk of myotoxicity. In CKD, Colchicine clearance is already reduced. This triple interaction (CKD + CYP3A4 inhibitor + statin) creates a perfect storm for Colchicine toxicity manifesting as diarrhoea, myopathy, rhabdomyolysis, and potentially multi-organ failure. Colchicine should be avoided or dose-halved when co-prescribed with CYP3A4 inhibitors, and the combination of all three should trigger an alert.

Reference: BNF 2024 – Colchicine Interactions; NICE CG169 – Gout