Posted by Sunnely on April 2, 2001, at 20:04:14
In reply to ELEVATED cpk, posted by mannetje on April 2, 2001, at 16:22:10
Hi Mannetje,
This question was posted sometime last year but will revisit to answer your questions.
CPK stands for creatine phosphokinase (the initial CK is more commonly used now). It is a muscle enzyme. It is a sensitive marker of muscle injury. The CPK considered normal is under 200. Marked elevations in CPK levels usually indicate muscle damage. There are 3 types of CPK: skeletal muscle, myocardium (heart), and brain.
Muscle CPK levels can rise significantly in the following conditions (not a complete list): 1. muscle trauma, 2. exercise, 3. cocaine intoxication, 4. alcoholism, 5. intramuscular injections, 6. psychotic agitation, 7. acute dystonic reactions (muscle stiffness), 8. malignant hyperthermia (occurs during anesthesia), 9. hypothermia, 10. coma, 11. infections involving muscles, 12. convulsions, 13. hypothyroidism (underactive thyroid), 14. cardiac catheterization, 15. surgery, 16. stroke, 17. prolonged immobilization, 18. neuroleptic malignant syndrome (NMS), and 19. CPK can also rise for no apparent reason and without medical explanation.
The particular concern with regards to elevations of CPK level in someone taking antipsychotics is the risk of NMS, a serious but fortunately rare adverse effect of antipsychotic drugs. However, CPK level elevation alone does not an NMS diagnosis make. The degree of elevations, the medications involved, the risks and health status of the person, the co-existing signs and symptoms, and ruling out other potential causes should all be taken into consideration before one is diagnosed with NMS. In one clinical study (Shalev et al. 1986), 92% of NMS cases had elevations of CPK. The usual range of CPK elevations is between 2000 - 15,000 but can be mildly elevated in some cases. On the other hand, CPK levels may not be elevated at all in some cases of definite NMS.
In a retrospective study (review of reported cases) of NMS induced by antipsychotics (Velamoor et al. 1994), they reported that NMS appear to follow a spectrum of events. The initial clinical picture in 82% of cases are acute mental status changes and extrapyramidal symptoms (EPS). The mental status changes usually consist of acute confusion, agitation or mutism, while the most common EPS symptom is rigidity. At this stage, stopping the antipsychotic drug usually reverses the condition. On the other hand, if the antipsychotic is not stopped, the condition may progress into a serious, full-blown NMS, usually within 48-72 hours. The 4 cardinal symptoms of a full-blown NMS are: 1. altered mental status (confusion, agitation, mutism), 2. EPS (rigidity), 3. autonomic instability (rapid pulse, rapid breathing, high or low blood pressure, profuse sweating), and 4. hyperthermia (104 or above not uncommon).
If your son is not experiencing any acute confusion, agitation, and especially mutism and muscle rigidity, his elevated CPK level (slight increase) is most probably not due to an impending NMS. Although anedotal cases of NMS have been reported with the use of Risperdal and Seroquel (also Clozaril and Zyprexa), if there are no corresponding signs and syptoms of acute mental status changes and EPS, I highly doubt your son is developing NMS.
Should the meds be discontinued immediately? Again, without corresponding signs and symptoms of acute mental status changes and EPS, I will not discontinue the meds due to high risk of psychotic relapse. However, he should be monitored for any mental status changes and EPS also monitor CPK levels.
Other causes of CPK elevations should also be explored. Physical exercise alone can cause elevations of CPK. Intramuscular injections and agitation can also cause elevations of CPK. Again, CPK levels can be elevated without medical explanation. I once knew of a person on antipsychotic with a persistent CPK level of 800+. He never showed symptoms indicative of possible NMS. Lots of medical tests done came up empty as to the cause.
Slightly elevated ALT (liver enzyme) happens a lot of times with antipsychotics (old and new). Not a reason to stop the medication based on this alone. A lot of times, the the liver enzymes return to normal after a few days or weeks. Also, these liver enzymes should be correlated clinically. If no corresponding symptoms of anorexia (loss of appetite), malaise, right upper quadrant (abdomen) pain, will not stop the medications (again due to high risk of psychotic relapse). Liver enzymes elevations from antipsychotics are usually mild, transient and asymptomatic. The suggested parameter as to when to stop the medication is if the liver enzymes (e.g., ALT, AST) reach 3X the upper normal value asymptomatic or not (especially if the medication is Depakote or Depakene). Of course, liver enzymes elevations pose a concern and I'm not trying to minimize this issue. But again, if it is only a slight elevation and without corresponding clinical symptoms, will just regularly monitor patient (labs and clinical picture) instead of stopping the medications (risk of psychotic relapse).
++++++++++++++++++++++++++++++++++> A question for CAm:
> My son has been takng 5mgs respirdol as well as 125mgs seroquel. He has an elevated CPK 228 on a normal range of 50-170] and also has slightly elevated ALT[liver enzyme]. The blood test was done when he was taking 5mgs respirdol +50mgs seroquel.
> Any info at all would be helpful. What kind of med change is would be most likely? What is the health hazard of this elevated cpk? How worried should I be? Should the meds be discountinued immediatley? My son's psychiatrist refused to order the blood tests so I sent my son to an MD who did them. Now the psychiatrist said that since I am interfering he will no longer treat my son. Any advice in this respect would also be appreciated. Thank You for your help.
>
poster:Sunnely
thread:58469
URL: http://www.dr-bob.org/babble/20010327/msgs/58494.html