renal function was stable based on
the SCr level, so it is more likely that
the elevated potassium level was a
sudden increase. The elevated potassium level and hypotension experienced in the SICU are consistent with
HPA suppression due to steroid use.
It is possible that the elevated potassium level could exacerbate the muscle weakness created from steroid
use and then NMBA. Because the patient’s sodium level was within normal limits preoperatively, Addison’s
disease and Cushing’s disease can be
Furthermore, it is important to
note the recent warnings and updated dosing and safety information
published in 2011 about a drug-drug
interaction between amlodipine and
simvastatin. Per updated labeling,
simvastatin doses should be limited
to 20 mg when taking concomitant
amlodipine due to an interaction
causing an increased risk for myalgia and rhabdomyolysis. 19 Most data
about myalgia showed an association
with pain in the extremities, specifically legs, and patients with rhabdomyolysis have some degree of renal
dysfunction. 19 This patient’s renal
function was stable, and there was
no documentation pertaining to myalgia in the patient’s extremities. Although the use of succinylcholine
could increase the patient’s risk for
rhabdomyolysis, the updated labeling
information does not comment on
The current recommendations on
steroid-induced myopathy include
perioperative steroid administration,
which occurred in this patient. Un-
fortunately, although the medication
and dose preoperatively were within
the current guidelines, it did not pro-
vide appropriate coverage to prevent
anesthetic complications or reintu-
bation. More research is needed to
support the use of HPA suppression
testing. It may lead to a correlation of
the extent of suppression with other
serious AEs of steroids, such as my-
opathy. Furthermore, a multidisci-
plinary team proved to be crucial in
the diagnosis and treatment of this
patient, especially in regards to drug-
drug interactions. Finally, this case
supports providers performing thor-
ough medication reconciliations with
patients, which is already the stan-
dard of care. It is imperative that pro-
viders are aware of potentially serious
outcomes associated with drug-drug
interactions, such as those involving
a combination of NMBAs with ste-
The authors report no actual or potential conflicts of interest with regard to
The opinions expressed herein are those
of the authors and do not necessarily
reflect those of Federal Practitioner,
Quadrant HealthCom Inc., a division
of Frontline Medical Communications,
Inc., the U.S. Government, or any of its
agencies. This article may discuss unlabeled or investigational use of certain
drugs. Please review complete prescribing information for specific drugs or
drug combinations—including indications, contraindications, warnings, and
adverse effects—before administering
pharmacologic therapy to patients.
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