What is the approach to managing elevated total creatinine kinase (CK) levels?

From the Guidelines

The management of elevated total creatinine kinase (CK) levels should prioritize identifying and addressing the underlying cause, ensuring adequate hydration, and monitoring for complications, with a focus on preventing kidney injury and managing potential electrolyte imbalances, as evidenced by recent studies 1. The approach to managing elevated CK levels involves a multi-faceted strategy, including:

• Discontinuing any medications that may be causing the elevation, such as statins 1
• Ensuring adequate hydration with intravenous or oral fluids to prevent kidney injury from myoglobin release 1
• Monitoring renal function, electrolytes, and serial CK levels every 12-24 hours until declining 1
• Resting the affected muscles and avoiding strenuous exercise until levels normalize 1
• Considering surgical consultation for fasciotomy in cases of compartment syndrome 1
• Switching to a different statin at a lower dose or alternative lipid-lowering therapy after CK normalization in cases of statin-induced myopathy 1 It is essential to note that the interpretation of CK levels can be complex, with various factors influencing the results, such as ethnicity, body composition, and exercise intensity 1. Adequate hydration is crucial, with aggressive IV hydration with normal saline at 200-300 mL/hour necessary for severe elevations (>5,000 U/L) to maintain urine output above 200 mL/hour 1. Electrolyte monitoring is also vital, as muscle breakdown releases intracellular potassium and phosphate while sequestering calcium 1. The most recent study 1 highlights the importance of considering individual factors, such as exercise modality and intensity, when interpreting CK levels, and the need for further research to establish evidence-based guidelines for managing workload in athletes.

From the Research

Approach to Managing Elevated Total Creatinine Kinase (CK) Levels

Elevated total creatinine kinase (CK) levels can be caused by various factors, including muscle damage, cardiovascular disease, and certain medications. The approach to managing elevated CK levels involves identifying the underlying cause and taking appropriate measures to address it.

• Differential Diagnosis: A thorough history and physical examination are essential to narrow down the possible causes of elevated CK levels 2. The patient's medical history, medication use, and symptoms such as muscle weakness or pain should be carefully evaluated.
• Laboratory Tests: Laboratory tests, including CK-MB mass and cardiac troponin I (cTnI), can help diagnose myocardial injury or muscular disease 3, 4. However, the utility of these tests may be limited in certain cases, such as muscular disease, where CK-MB mass may be elevated even after treatment 4.
• Medication-Induced CK Elevation: Certain medications, including tyrosine kinase inhibitors (TKIs), can cause CK elevation 5. In such cases, dose reduction or alternative treatments may be necessary to manage CK elevation-related symptoms.
• Clinical Management: The clinical management of elevated CK levels depends on the underlying cause. In cases of muscle damage or disease, treatment may involve physical therapy, pain management, and monitoring for potential complications 2. In cases of cardiovascular disease, treatment may involve medications to manage cardiac function and prevent further damage 3.
• Monitoring and Follow-up: Regular monitoring of CK levels and clinical symptoms is essential to ensure that the underlying cause is being effectively managed 2. Patients with hyperCKemia of uncertain etiology may require longitudinal surveillance to monitor for potential consequences.

Considerations for Specific Patient Populations

• Psychiatric Patients: In psychiatric patients, elevated CK levels may be caused by antipsychotic-induced rhabdomyolysis or neuroleptic malignant syndrome 6. Careful monitoring of symptoms and potential complications is critical to avoid devastating clinical consequences.
• Cancer Patients: In cancer patients, CK elevation may be caused by TKI treatment 5. The incidence of CK elevation-induced by certain TKIs can be over 35%, and high-level or severe symptomatic CK elevation may necessitate dose reduction.