Does Creatine Supplementation Increase the Risk of Rhabdomyolysis?

When you want to get strong, creatine for many is the supplement of choice. When you train at high intensities, rhabdomyolysis is a potential threat. Below is an example of an adverse reaction to creatine, posted by Ralph Giarnella MD on Supertraining.

For additional reading on creatine and rhabdo, there are some good links posted at the end of the article.

Does Creatine Supplementation Increase the Risk of
Rhabdomyolysis?

Mark S. Juhn, DO, Hall Health Primary Care Center,
Family Medicine and Sports Medicine Clinics,
University of Washington, Seattle.
J Am Board Fam Pract 13(2):150-151, 2000. © 2000
American Board of Family Practice
Introduction
The case report by Robinson[1] in this issue of The
Journal represents the most serious published report
to date of an adverse effect in a person taking oral
creatine supplements. In light of its severity, it is
prudent to speculate on the likelihood that this man’s
creatine consumption contributed to his
rhabdomyolysis.
Rhabdomyolysis results from a breakdown of the muscle
cell wall, which leads to cell necrosis. It is thought
to be the result of a plasma membrane defect or a
disturbance in the sodium-potassium pump that allows
an influx of calcium into the cell, which triggers a
cascade of events leading to cell necrosis.[2]
Robinson speculates that intracellular water retention
led to increased skeletal muscle compartment
pressures, which placed the patient at risk for
cellular wall breakdown.
Such a hypothesis is simplistic yet worthy of
consideration. It is accepted that oral creatine
supplementation results in a rapid weight gain, easily
noted within 24 hours.[3,4] Clearly, 24 hours is not
enough to induce skeletal muscle hypertrophy; the gain
is the result of intracellular and extracellular fluid
retention. Although no studies have evaluated creatine
supplementation and its effect on muscle compartment
pressures, anecdotal evidence of athletes feeling
“tight” or “cramped” abounds. Muscle cramping remains
one of the most common side effects reported by those
taking creatine.[5,6]
Risk factors for rhabdomyolysis include dehydration,
alcoholism, illicit drug use, trauma, strenuous
exercise, hypophosphatemia, and a hyperosmolal
state.[2,7,8] Robinson’s patient had exercised the day
before Robinson saw him, though his fluid and
electrolyte status were not known. It has been
hypothesized that creatine supplementation increases
the risk of dehydration from intravascular volume
depletion. Even creatine manufacturers recommend a
healthy fluid intake while on creatine supplements.
Rhabdomyolysis has been reported in athletes who were
not taking creatine supplements. There are factors,
however, that suggest creatine was at least a
contributing factor. First, as do many athletes who
believe more is better, this patient was taking a very
high dose for an extended time. Such high doses and
long periods are not only contrary to recommendations,
but they are also unstudied. Second, he was previously
healthy and had been body building for 5 years; only
during the last year was he taking creatine
supplements. Third, he was not taking any other
supplement that could be a contributing factor.
Advocates of creatine supplementation often state
there is no direct evidence of a causal relation
between oral creatine supplementation and any adverse
side effect. Such a statement is often misinterpreted
as proof that creatine is safe. Establishing a
statistically significant relation, however, between a
catastrophic event such as rhabdomyolysis and any type
of supplement is unrealistic, particularly when using
human subjects.
As clinicians, we need to evaluate such cases by
incorporating a balance between healthy skepticism and
open-mindedness. Given the metabolic and physiologic
changes that occur with oral creatine supplementation,
combined with the excessive dosing, Robinson’s case
adds support to the hypothesis that the use of oral
creatine supplements can lead to serious adverse
effects. More importantly, it brings to mind the
question that has been plaguing many for years about
the role of ergogenic aids for sport: Is it really
worth it?

References
1. Robinson SJ. Acute quadriceps compartment syndrome
and rhabdomyolysis in a weight lifter using high-dose
creatine supplementation. J Am Board Fam Pract
2000;13:134-7.
2. Poels PJ, Gabreels FJ. Rhabdomyolysis: a review of
the literature. Clin Neurol Neurosurg 1993;95:175-92.
3. Hultman E, Soderlund K, Timmons JA, Cederblad G,
Greenhaff PL. Muscle creatine loading in men. J Appl
Physiol 1996;81:232-7.
4. Vandenberghe K, Goris M, Van Hecke P, Van
Leemputte M, Vangerven L, Hespel P. Long-term creatine
intake is beneficial to muscle performance during
resistance training. J Appl Physiol 1997;83:2055-63.
5. Juhn MS, O’Kane JW, Vinci DM. Oral creatine
supplementation in male collegiate athletes: a survey
of dosing habits and side effects. J Am Diet Assoc
1999;5:593-5.
6. LaBotz M, Smith BW. Creatine supplement use in an
NCAA Division I athletic program. Clin J Sport Med
1999;9:167-9.
7. Knochel JP. Mechanisms of rhabdomyolysis. Curr
Opin Rheumatol 1993;5:725-31.
8. Singhal PC, Kumar A, Desroches L, Gibbons N,
Mattana J. Prevalence and predictors of rhabdomyolysis
in patients with hypophosphatemia. Am J Med
1992;92:458-64.

Reprint Address
Address reprint requests to Mark S. Juhn, DO, Hall
Health Primary Care Center, Family Medicine and Sports
Medicine Clinics, University of Washington, Box
354410, Seattle, WA 98195-4410.

———————————
For additional reading, take a look at “Creatine: A Review of Efficacy and Safety”. You will have to register to Medscape to view the article.

On Rhabdomyolysis, here is some great info.

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