Clinical Communication to the Editor| Volume 131, ISSUE 8, e333-e334, August 2018

Sudden Creatine Kinase Elevation When an Athlete Starts Boxing: Looking Deeper Prior to Knocking the Statin Out

      A 55-year-old Caucasian man with a prior computed tomography calcium score in the 75th percentile for age, sex, and race at age 39 years, and on long-term high-intensity statin therapy presented with episodic myalgia. He reported 3 episodes within the past year of sudden severe quadriceps pain that self-resolved within 2 days. His activities included biking 10 hours per week, weight lifting 3 times per week, and a new activity, boxing, for 2-3 hours per week. On 80 mg/day of atorvastatin for 10 years, 6 months prior to presentation his dose was reduced to 40 mg/day due to muscle symptoms. After another episode of quadriceps pain, the patient visited his primary physician where labs showed an elevated creatine kinase (CK) level of 28,190 IU/L (Table 1). Atorvastatin was stopped and a systematic investigation into the etiology of his CK elevation revealed that boxing was the culprit. After an extensive risk–benefit discussion, treatment was initiated with 10 mg ezetemibe. His symptoms improved initially but recurred when he resumed boxing. Ezetemibe was stopped and the patient's low-density lipoprotein cholesterol began to increase (Table 1). After another risk–benefit discussion, he agreed to stop boxing and was started on rosuvastatin 5 mg every other day, which he is currently tolerating well.
      Table 1Patient's LDL-C, CK, and Cr Relationship to Statin Therapy
      Date LDL-C (mg/dL) CK (IU/L) Cr (mg/DL) Boxing Statin Therapy at Time
      5/19/16 28,190 0.8 Yes Atorvastatin 40
      6/8/16 90 412 0.91 No None
      6/29/16 106 444 0.91 No None
      9/8/16 90 576 1.01 No Ezetemide 10 mg
      1/17/17 91 197 0.98 No Ezetemide 10 mg
      8/4/17 124 268 0.98 No None
      9/28/17 80 834 0.92 Yes Rosuvastatin 5 mg (every other day)
      10/23/17 331 No Rosuvastatin 5 mg (every other day)
      2/27/18 112 505 (1 h post aerobic exercise) No Rosuvastatin 5 mg (every other day)
      3/17/18 365 (24-h post aerobic exercise)
      CK = creatine kinase; Cr = Creatinine; LDL = low-density lipoprotein cholesterol.
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