Case Report
A 58-years old man, a Municipal employee with athletic experience presented with two tendon ruptures in the rotator cuff tendon in different shoulders after two minor traumas.
He had a history of ischemic heart disease and went under percutaneous coronary intervention (PCI) procedure (4 years ago), 10 year-ASCVD risks score 22.7%, benign prostate hypertrophy, hypertension and diabetes mellitus. He has been prescribed 40mg Atorvastatin once a day, 0.4mg Tamsulosin once daily, 5mg Amlodipine once daily, Dutasteride 0.5mg once a day, Metoprolol 12.5mg every 12 hours, Metformin 500 mg every 8 hours, Pioglitazone 15mg every day, and ASA 80mg once a day. The patient has no history of alcohol or smoking. He has a familial history of hypertension and heart disease.
Before these accidents, the patient remembers having aches in both his shoulders after playing sports, like soccer which he did not experience before. The first trauma occurred in 2020 when the patient was climbing a gentle slope mountain. He slipped on his left hand and suffered pain at that moment but it was light enough for him to be neglected, and he didn’t seek medical advice. He also mentions that similar accidents had happened before, too but he got better in a little time. After some time (he can’t recall specifically), the patient had the same falling accident while participating in an indoor soccer match. It caused too much pain in his shoulder that made the patient visit a doctor. The pain was intense and he had difficulty raising his hand.
MRI (figure 1) ordered for him. Full-thickness tearing seen at the critical zone of the supraspinatus tendon. It was related to this minor trauma. That was why the doctor performs surgery on him and did not change his drugs. also partial tearing in right rotator cuff tendon was present at that time but it was not diagnosed and no action was taken against it. After two years he slipped on his right hand which caused the same pain that he experienced two years before.it was intense, non-radiating pain that worsened at night and especially when he abducted his hand. He visited a doctor again and was ordered to do an MRI (figure 2). The evidence of complete tearing in the rotator cuff tendon was seen besides joint effusion. So he went under Arthroscopic tendon repair procedure for the second time.
After these two minor traumas, suspicion was raised about atorvastatin side effects to be the real cause.
The Naranjo adverse drug reaction (ADR) probability scale was calculated, and the patient achieved a score of 7, which means tendon rupture probably happened due to atorvastatin.
Additional investigation was done which was normal.
Finally, due to the recurrent tendon rupture and Naranjo scale score, Atorvastatin was considered as the causative agent and it was discontinued.
As for the high score of 10 year-ASCVD risks, it was necessary to prescribe an alternative drug with mortality-reducing effects in cardiovascular patients, as same as statins. After enough studies, Evolocumab 140mg once in two weeks, was selected as an alternative from the family of PCSK9 inhibitors.