Case Presentation: A 75-year-old female with a history of mild Lewy body dementia, hypothyroidism, hypertension and cryptogenic cirrhosis presented to the hospital with complaints of jaw pain and right gluteal pain. She had been prescribed a 7-day course of amoxicillin/clavulanate two days prior for a cat bite. Two weeks prior, her furosemide had been increased to manage lower extremity swelling. Laboratory evaluation revealed a creatine kinase (CK) of 2330 U/L. Her home medication list included atorvastatin 20 milligrams daily, but no other medications associated with rhabdomyolysis. CT scan of the pelvis was negative for significant gluteal pathology. On admission, the etiology of her rhabdomyolysis remained uncertain. She was admitted for conservative fluid hydration and lab monitoring. Given her clinical stability, she was transferred to the hospital-at-home to receive her hospital care. During her care in the hospital-at-home, several pieces of new clinical information were revealed that had not been previously documented in the medical record or obtained during her brick&mortar evaluation. She had both 20-milligram and 40-milligram atorvastatin pills in her home and frequently took both in the same day. She often had difficulty remembering if she had taken her medications, leading her to sometimes taking extra doses. This was supported by her amoxicillin/clavulanate supply being exhausted, even though she should have had five more days’ worth. She also consumed at least three grapefruits per day. Her rhabdomyolysis was attributed to accidental statin overuse in the setting of significant grapefruit consumption, potentially exacerbated by her cirrhosis and dehydration in the setting of recent diuretic dosage increase. She received four lactated ringer boluses over the course of her admission. Her CK gradually down trended and was 727 U/L at the time of discharge. To reduce the risk of recurrence, her daughter was recruited to dispose of all old medications and to fill pill boxes for the patient going forward. Her statin was discontinued in the setting of a low cardiovascular disease risk. Her PCP was contacted and agreed to monitor this issue and review any medication changes from her subspecialists.
Discussion: In this patient, multiple factors likely contributed to her CK elevations, including her statin overuse and grapefruit consumption. Grapefruit consumption is associated with increased statin blood levels in patients taking non-hydrophilic statins (simvastatin, atorvastatin and lovastatin). Patients taking these medications should be advised to limit their grapefruit consumption to half a grapefruit or less daily. Challenges with medication management and other home factors can be significant contributors to patients’ medical problems. These can be challenging to identify when the patient is being evaluated in a traditional brick-and-mortar hospital, even with pharmacy-performed medication reconciliation. The patient’s home environment in a hospital-at-home can be directly observed, a particular benefit of care in this model. If this patient had the patient been hospitalized in a traditional brick & mortar setting, the etiology of her rhabdomyolysis would have likely remained undetermined.
Conclusions: In addition to other benefits, care in a hospital-at-home can reveal contributing factors to a patient’s illness that go unrecognized in more traditional healthcare settings.