Professional Documents
Culture Documents
International Immunopharmacology
journal homepage: www.elsevier.com/locate/intimp
Department of Medical Microbiology and Immunology, Creighton University, 2500 California Plaza, Omaha, NE 68178, USA
Department of Pathology and Microbiology, University of Nebraska Medical Center, 986495, Nebraska Medical Center, Omaha, NE 68198-6495, USA
Department of Exercise Science and Pre-Health Professions, Creighton University, 2500 California Plaza, Omaha, NE 68178, USA
a r t i c l e
i n f o
Article history:
Received 1 October 2015
Received in revised form 15 December 2015
Accepted 22 December 2015
Available online xxxx
Keywords:
Creatine
Immune response
Immunomodulation
Neuroprotection
a b s t r a c t
Creatine is widely used by both elite and recreational athletes as an ergogenic aid to enhance anaerobic exercise
performance. Older individuals also use creatine to prevent sarcopenia and, accordingly, may have therapeutic
benets for muscle wasting diseases. Although the effect of creatine on the musculoskeletal system has been
extensively studied, less attention has been paid to its potential effects on other physiological systems. Because
there is a signicant pool of creatine in the brain, the utility of creatine supplementation has been examined
in vitro as well as in vivo in both animal models of neurological disorders and in humans. While the data are
preliminary, there is evidence to suggest that individuals with certain neurological conditions may benet
from exogenous creatine supplementation if treatment protocols can be optimized. A small number of studies
that have examined the impact of creatine on the immune system have shown an alteration in soluble mediator
production and the expression of molecules involved in recognizing infections, specically toll-like receptors.
Future investigations evaluating the total impact of creatine supplementation are required to better understand
the benets and risks of creatine use, particularly since there is increasing evidence that creatine may have a
regulatory impact on the immune system.
2015 Elsevier B.V. All rights reserved.
1. Introduction
Creatine is naturally synthesized in the liver, kidney, and pancreas of
vertebrates from the amino acids arginine, methionine, and glycine
[13]. In vivo, creatine is a product of the arginine biosynthesis pathway
and metabolizes to creatinine [3,4]. Individuals who eat meat and/or
sh obtain approximately 1 g d 1 of creatine from the diet [5], and
approximately 1 g d1 is synthesized endogenously. Vegetarians have
signicantly lower muscle creatine stores and lower creatinine levels
as compared to those who eat meat and/or sh products [6,7]. The
average creatine pool for a 70 kg individual ranges from 120140 g
and approximately 2 g d1 is lost in the urine in the form of creatinine
[1]. Given that daily intake and excretion are approximately equal, the
most efcient way to increase creatine stores in the body is through dietary supplementation. Creatine enters the muscle cells via a sodiumand chloride-dependent creatine transporter [3,8,9] and is primarily
stored in the skeletal muscle as free creatine or phosphocreatine,
which is a major source of energy to the host [3,8,10].
While the majority of creatine in the body is stored in skeletal
muscles [3], there is also a signicant pool of creatine in the brain [11],
http://dx.doi.org/10.1016/j.intimp.2015.12.034
1567-5769/ 2015 Elsevier B.V. All rights reserved.
Please cite this article as: L.A. Riesberg, et al., Beyond muscles: The untapped potential of creatine, Int Immunopharmacol (2015), http://
dx.doi.org/10.1016/j.intimp.2015.12.034
energy system is the metabolic system that produces ATP most rapidly,
as compared to glycolysis or the aerobic system [27]. Inside the cell,
creatine phosphokinase catalyzes a reversible reaction between the
-phosphate group of ATP to the guanidino group of creatine resulting
in ADP and phosphocreatine (Fig. 1). Cellular stores of phosphocreatine
can reach concentrations of up to 40 mM [3,8,2830] and is essential for
replenishing ATP stores that are immediately used during high intensity
exercise.
Dietary creatine supplementation increases the phosphocreatine
stores in the muscles, and has been shown to enhance performance
during high-intensity, short duration activities or repeated bouts of
high-intensity exercise with short rest periods such as jumping,
sprinting, and strength training [26,3139]. It is estimated that 2778%
of all college athletes have used creatine supplements [4043] and the
proportion of individuals using creatine is likely much higher in athletes
participating in sports such as football, track, wrestling, and soccer
[26,3134,44]. A recent study of body builders in Iran reported that
creatine was the most common nutritional supplement used by men
(60.8%) [35]. Initially, creatine was primarily utilized by elite athletes;
but its use has become increasingly widespread among older adults,
recreational athletes, and high school athletes [1,4551].
The most widely used form of creatine by athletes is creatine
monohydrate [4143]. Oral bioavailability of creatine monohydrate is
low due to the rapid conversion of creatine to creatinine in acidic
environments, as would be encountered in the stomach [52,53]. While
there has been little study examining how creatine crosses the intestine,
the small intestine does express the Na+/Cl creatine transporter [54]
which is also expressed in other organs including the brain, kidney, and
heart [55,56]. However, some work has suggested that creatine may
move across the jejunum by paracellular movement [57]. The contributions of each of these potential mechanisms of transport is unclear although it has been shown that creatine supplementation of individuals
decient in the creatine transporter does improve muscular, but not
cognitive and psychiatric symptoms of the condition [58], indicating
that paracellular transport may be a sufcient to increase creatine stores
in the muscles.
Athletes normally engage in the practice of loading that consists of
ingesting 20 g d1 of creatine for ve days administered over several
(usually four) doses followed by 110 g d 1 for several weeks or
months [3,34]. The loading phase increases muscle stores of phosphocreatine 15 to 40% [59,60]. Minimal side effects as a result of the creatine
loading phase have been reported and include cramping, nausea, uid
retention, and diarrhea [43,61]. Although it is typically recommended
that individuals creatine load for 47 days, it has been reported that creatine uptake into muscle is greatest during the rst 2 days of loading
[62]. Hultman et al. [63] have also reported that a dose of 3 g d1 for
28 days is as effective as creatine loading for increasing total muscle
creatine stores. Therefore, slowly loading the muscle with creatine
may result in signicant increases in performance and alleviate side
effects that are sometimes associated with a 47 day loading regimen.
Very few individuals (~20% of users) reach maximal creatine saturation of their skeletal muscles (160 mmol/kg dry mass [10]), thus there is
signicant interest in developing formulations that have enhanced bioavailability. One currently available form of creatine, creatine ethyl
ester, is reported to have a greater degree of stability and bioavailability
than creatine monohydrate [53]. It is postulated that because the
carboxyl group is no longer available, creatine ethyl ester is not converted to creatinine in the stomach, but can be absorbed in the intestine
where the creatine ethyl ester enters the blood. Esterases in the intestinal cells and blood convert the creatine ethyl ester to creatine, which is
then stored in the muscle cells as phosphocreatine. Of particular note,
creatine ethyl ester is more stable than creatine monohydrate at a
lower pH (as would be encountered in the stomach) [52,53]. In addition,
in vitro studies utilizing Caco-2 cell monolayers have demonstrated increased permeability of creatine ethyl ester compared to creatine
monohydrate [53]. Together, these studies [52,53] suggest that creatine
ethyl ester may be more bioavailable than creatine monohydrate.
There are multiple mechanisms by which creatine functions to enhance athletic performance. As shown in Fig. 1, creatine is the substrate
for the creatine kinase reaction, resulting in the generation of phosphocreatine, which comprises 60% of the creatine in skeletal muscle (~60%
of muscle creatine is stored as phosphocreatine and 40% as free
creatine) [2]. As previously mentioned, phosphocreatine is responsible
for the re-phosphorylation of ADP to ATP during bursts of high intensity
movements, thus resulting in an increased availability of energy during
short periods of explosive exercise [3539,64]. As phosphocreatine
levels decline due to the re-phosphorylation of ADP, phosphofructokinase production is stimulated, thereby increasing the rate of glycolysis
[39]. Creatine can also function to buffer the pH changes that occur
due to the accumulation of lactate and hydrogen ions by using the
hydrogen ions in the creatine kinase reaction [65,66]. Individuals with
creatine or phosphocreatine deciencies due to genetic defects in proteins
involved in creatine synthesis (L-arginineglycine amidinotransferase or
guanidinoacetate methyltransferase) or transport (creatine transporter
[SLC6A8]) have reduced levels of ATP in the brain resulting in developmental delays and mental retardation [6769]. While individuals with
defects in creatine synthesis can be treated with exogenous creatine, no
treatment exists for individuals with decits in the creatine transporter
[6769].
3. Creatine as a mediator of neuroprotection
3.1. The mitochondrial permeability transition pore
Because of the high levels of creatine in the central nervous system
[11], a considerable number of studies have focused on the potential neuroprotective effects of oral creatine supplementation in a variety of neurological conditions including traumatic brain injury (TBI) [12,70,71],
Huntington's Disease (HD) [13,7276], amyotrophic lateral sclerosis
(ALS) [14,7780], cerebral ischemia [15,81], and Parkinson's Disease
(PD) [8288]. One of the key focuses as to how creatine may work to reduce neuropathology in the central nervous system (CNS) has been the
effect of creatine on the mitochondrial permeability transition pore
[14,89]. In the CNS, the mitochondrial permeability transition pore is induced in the conditions mentioned above including stroke [90], PD
[91,92], HD [93], TBI [94,95], and ALS [14,96,97]. The mitochondrial
permeability transition pore is also induced by reactive oxygen species
(ROS) [98] and, correspondingly, ROS are released as a result of development of the pore [99]. Conversely, high ATP and ADP levels prevent the
mitochondrial pore from being induced [98,100,101].
Excitotoxicity is a major cause of neuronal death that is the result
of an inux of calcium into the cell as a result of glutamate receptor
Fig. 1. The arginine biosynthesis pathway. Creatine is generated as part of the arginine biosynthesis pathway. Creatine and phosphocreatine exist in equilibrium in the cell. Creatine
phosphokinase catalyzes the reaction between creatine and phosphocreatine, which results in energy (ATP) generation. Hydrolysis of phosphocreatine yields the end product of the
pathway, creatinine. SAM, S-adenosyl-methionine; SAH, S-adenosyl-homocysteine
Please cite this article as: L.A. Riesberg, et al., Beyond muscles: The untapped potential of creatine, Int Immunopharmacol (2015), http://
dx.doi.org/10.1016/j.intimp.2015.12.034
Please cite this article as: L.A. Riesberg, et al., Beyond muscles: The untapped potential of creatine, Int Immunopharmacol (2015), http://
dx.doi.org/10.1016/j.intimp.2015.12.034
Please cite this article as: L.A. Riesberg, et al., Beyond muscles: The untapped potential of creatine, Int Immunopharmacol (2015), http://
dx.doi.org/10.1016/j.intimp.2015.12.034
Table 1
Summary of in vivo studies examining the effects of oral creatine on inammation.
Species
Model
Dose
Results
Reference
Rat
Carrageean-induced edema
Nystatin-induced edema
5-HT-induced edema
Formaldehyde-induced arthritis
Granuloma pouch
OVA sensitization
OVA sensitization + exercise
OVA sensitization
50500 mg kg1
500 mg kg1
500 mg kg1
100500 mg kg1
100 mg kg1 7 d
0.5 g kg 1 d1
0.5 g kg1 d1
0.5 g kg1 d1
Reduced swelling
Reduced swelling
Reduced paw volume
Reduced paw volume
Reduced exudate, reduced pouch weight
Increased allergic inammation, airway responsiveness, airway remodeling
Low intensity exercise reduced negative effects of creatine
Increased allergic inammation and airway remodeling
[19]
Mouse
Mouse
Mouse
[24]
[220]
[221]
Please cite this article as: L.A. Riesberg, et al., Beyond muscles: The untapped potential of creatine, Int Immunopharmacol (2015), http://
dx.doi.org/10.1016/j.intimp.2015.12.034
in reality, the opposite may be true [211214]. While there could be several factors to explain this, strenuous exercise increases the levels of T
helper 2 (Th2) cytokines [215218] along with other factors that also
impact airway remodeling. While the factors that impact the severity
of asthma are not completely dened, the intensity of exercise appears
to be one factor, thus the casual exerciser may experience improvements in their asthma, while elite athletes may have a deterioration of
their condition.
A related study focused on the impact of creatine supplementation
on allergic inammation and airway remodeling in a mouse model of allergic asthma [24]. This investigation was based upon the observation
that 1) the rate of asthma in athletes is higher than that observed in
the general population; and 2) athletes are more likely to use creatine
supplementation than the general population. The impact of creatine
supplementation on female BALB/c mice with OVA-induced airway
hyper-responsiveness was examined [24]. Under normal circumstances
(that is, in the absence of creatine treatment), this particular model of
airway hyper-responsiveness was characterized by a strong Th2 response in mice with high levels of IL-4, IL-5, and insulin-like growth
factor-1 (IGF-1) [219]. The mice also developed thickened airway
smooth muscles and collagen and elastic ber deposition along with eosinophil inltration of the airways. After creatine monohydrate treatment of the OVA-sensitized animals, mice experienced increased
levels of IL-4, IL-5, IGF-1, eosinophil inltration of the airways, increased
smooth muscle thickness, and increased levels of collagen and elastic
bers in the lungs. Interestingly, the control group that was not OVA
sensitized, but received creatine also experienced signicant alterations
in airway physiology and immune responses consistent with allergic inammation [24], demonstrating that creatine, in and of itself, may be a
risk factor for the development of asthma. The data also demonstrated a
skewing of the immune response towards a more profound Th2-like response. As a follow-up to these studies, the impact of exercise on the
creatine-induced changes in OVA-sensitized mice was examined
[220]. The data demonstrated that exercise can reduce the effects of
creatine in the model, since mice that completed a low intensity exercise regimen showed reduced numbers of eosinophils, numbers of IL-5
and IL-4 positive cells, and other pathological changes in the lungs indicative of airway hypo-responsiveness compared to animals that did not
exercise [220]. Collectively, the data leads to the intriguing possibility
that individuals with Th2-mediated diseases (i.e., allergy, asthma,
lupus) could exacerbate their disease if they supplement their diet
with creatine monohydrate. The results of these studies also lead to
the question of whether creatine has the potential to alleviate Th1mediated immunopathology.
The ability of creatine to impact various respiratory disease states is
not limited to its effects on cells of the immune system. Ferreira et al.
[221] examined the effects of creatine supplementation on the airway
epithelium in the mouse model of OVA-induced allergic asthma.
Creatine supplementation of the OVA-sensitized mice had decreased
NF- activation in epithelial cells compared to the level observed in
the non-creatine supplemented, OVA-sensitized mice [221]. Since this
transcription factor acts as a master regulator for the immune response
[222224], this alteration of NF- activation resulted in increased
expression of IL-5, CCL5, CCL2, TIMP-1, matrix metalloproteinase-9
(MMP-9), transforming growth factor-1 (TGF-1), IGF-1, EGFR,
TIMP-2, and MMP-12 in epithelial cells compared to non-creatine supplemented OVA-sensitized mice. Because of these widespread alterations in immune mediators, the authors examined the levels of NF-
in the epithelial cells of mice [221]. These mediators are associated not
only with inammation, but also with airway remodeling. The chemokine CCL-5 is involved in recruitment of eosinophils, a key cell type in
asthma, while CCL2 recruits dendritic cells, T cells, and monocytes to
the site. Together, these data provide insight into why some athletes
may have a higher than normal rate of asthma than the general population, and therefore, should be cautioned before beginning a creatine
supplementation program.
Please cite this article as: L.A. Riesberg, et al., Beyond muscles: The untapped potential of creatine, Int Immunopharmacol (2015), http://
dx.doi.org/10.1016/j.intimp.2015.12.034
Fig. 2. ICAM-1 expression is upregulated in mouse macrophages following exposure to 10 mM creatine monohydrate. Immunohistochemical staining revealed an increase in ICAM-1 signal
after incubation with 10 mM creatine monohydrate for 24 (B) or 48 (C) hours. Control (A) cells were incubated with culture media alone. Non-specic staining controls received rat IgG
(isotype control) in lieu of primary antibody (D). Immunohistochemical staining for ICAM-1 was performed using the Avidin Biotin Complex (ABC) method (Vector Laboratories) as
previously described [238] using an antibody to mouse ICAM-1 (BD Pharmingen). Development was performed using the AEC Substrate Kit (Vector Laboratories). Positive staining is
indicated by the brown reaction product.
approached the levels observed in control DNA that was not exposed
to ROS [237]. Further studies utilizing HUVEC cells that were pretreated
with creatine for 24 h then exposed to hydrogen peroxide demonstrated that creatine treated cells had increased viability compared to control
cells, and that creatine pretreatment also protected mitochondrial DNA
from signicant damage compared to the control cells [237]. In addition,
the nuclear DNA experienced less damage than the mitochondrial DNA
in both control and creatine-treated cells, however, the differences
between treatments were not statistically signicant. In total, these
studies [235237] suggest that creatine has direct antioxidant activity
and that both cell viability and the levels of DNA damage are positively
affected by exposure to creatine.
5. Conclusions
Creatine has been used by athletes as an ergogenic aid since the
1970s. Herein, we describe potential uses for creatine in the clinical setting. Of note, creatine is extremely inexpensive compared to most neuroprotective agents and immunomodulatory drugs. It is critical that
future studies in humans examining the neuroprotective properties of
creatine are designed to ensure that participants are ingesting doses
that parallel the doses used in rodent studies. Furthermore, it is of
great interest to continue to explore the potential of this ergogenic supplement in animal models of disease to better understand the
mechanism(s) of action of creatine in vivo. Given creatine's impact on
the immune system studies in models of autoimmune disease may be
particularly applicable.
Acknowledgments
The authors are grateful to Luciano Trevor Holzmer and Sara Pitz for
their expertise and assistance in generating the graphical abstract.
This work was performed in a facility supported by Grant Number 1
C06 RR17417-01 from the National Center for Research Resources
Fig. 3. IL-6 expression is downregulated by mouse macrophages following exposure to 10 mM creatine monohydrate. Immunohistochemical staining demonstrated a decrease in IL-6
expression following incubation with 10 mM creatine monohydrate for 24 (B) or 48 (C) hours. Control (A) cells were incubated with media alone. Non-specic staining controls
received rat IgG (isotype control) in lieu of primary antibody (D). Immunohistochemical staining for IL-6 was performed using the Avidin Biotin Complex (ABC) method (Vector
Laboratories) as previously described [238] using an antibody to mouse IL-6 (BD Pharmingen). Development was performed using the AEC Substrate Kit (Vector Laboratories). Positive
staining is indicated by the brown reaction product.
Please cite this article as: L.A. Riesberg, et al., Beyond muscles: The untapped potential of creatine, Int Immunopharmacol (2015), http://
dx.doi.org/10.1016/j.intimp.2015.12.034
(KMD). The content is solely the responsibility of the authors and does
not necessarily represent the ofcial views of the National Center for
Research Resources or the National Institutes of Health.
References
[1] M.G. Bemben, M.S. Witten, J.M. Carter, K.A. Eliot, A.W. Knehans, D.A. Bemben, The
effects of supplementation with creatine and protein on muscle strength following
a traditional resistance training program in middle-aged and older men, J. Nutr.
Health Aging 14 (2010) 155159.
[2] J.B. Walker, Creatine: biosynthesis, regulation, and function, Adv. Enzymol. 50
(1979) 177252.
[3] M. Wyss, R. Kaddurah-Daouk, Creatine and creatinine metabolism, Physiol. Rev. 80
(2000) 11071213.
[4] W. Drge, Free radicals in the physiological control of cell function, Physiol. Rev. 82
(2002) 4795.
[5] P.D. Balsom, K. Sderlund, B. Ekbolm, Creatine in humans with special reference to
creatine supplementation, Sports Med. 18 (1994) 268280.
[6] J. Delanghe, J.P. DeSlypere, M. DeBuyzere, J. Robbrecht, R. Wieme, A. Vermeulen,
Normal reference values for creatine, creatinine, and carnitine are lower in
vegetarians, Clin. Chem. 35 (1989) 18021803.
[7] A. Shomrat, Y. Weinstein, A. Katz, Effect of creatine feeding on maximal exercise
performance in vegetarians, Eur. J. Appl. Physiol. 82 (2000) 321325.
[8] R.J. Snow, R.M. Murphy, Creatine and the creatine transporter: a review, Mol. Cell.
Biochem. 224 (2001) 169181.
[9] O. Speer, L.J. Neukomm, R.M. Murphy, E. Zanolla, U. Schlattner, H. Henry, R.J. Snow,
T. Wallimann, Creatine transporters: a reappraisal, Mol. Cell. Biochem. 256-257
(2004) 407424.
[10] P. Greenhaff, The nutritional biochemistry of creatine, J. Nutr. Biochem. 8 (1997)
610618.
[11] O. Braissant, H. Henry, M. Loup, B. Eilers, C. Bachmann, Endogenous synthesis and
transport of creatine in the rat brain: an in situ hybridization study, Mol. Brain Res.
86 (2001) 193201.
[12] P.G. Sullivan, J.D. Geiger, M.P. Mattson, S.W. Scheff, Dietary supplement creatine
protects against traumatic brain injury, Ann. Neurol. 48 (2000) 723729.
[13] R.J. Ferrante, O.A. Andreassen, B.G. Jenkins, A. Dedeoglu, S. Kuemmerle, J.K. Kubilus, R.
Kaddurah-Daouk, S.M. Hersch, M.F. Beal, Neuroprotective effects of creatine in a transgenic mouse model of Huntington's disease, J. Neurosci. 20 (2000) 43894397.
[14] P. Klivenyi, R.J. Ferrante, R.T. Matthews, M.B. Bogdanov, A.M. Klein, O.A.
Andreassen, G. Mueller, M. Wermer, R. Kaddurah-Daouk, M.F. Beal, Neuroprotective effects of creatine in a transgenic animal model of amyotrophic lateral
sclerosis, Nat. Med. 5 (1999) 347350.
[15] S. Zhu, M. Li, B.E. Figueroa, A. Liu, I.G. Stavrovskaya, P. Pasinelli, M.F. Beal, R.H.
Brown, B.S. Kristal, R.J. Ferrante, R.M. Friedlander, Prophylactic creatine administration mediates neuroprotection in cerebral ischemia in mice, J. Neurosci. 24
(2004) 59095912.
[16] R.T. Matthews, R.J. Ferrante, P. Klivenyi, L. Yang, A.M. Klein, G. Mueller, R.
Kaddurah-Daouk, M.F. Beal, Creatine and cyclocreatine attenuate MPTP neurotoxicity, Exp. Neurol. 157 (1999) 142149.
[17] A. Nomura, M. Zhang, T. Sakamoto, Y. Ishii, Y. Morishima, M. Mochizuki, T. Kimura,
Y. Uchida, K. Sekizawa, Anti-inammatory activity of creatine supplementation in
endothelial cells in vitro, Br. J. Pharmacol. 139 (2003) 715720.
[18] B.R. Madan, N.K. Khanna, Effect of creatinine on various experimentally induced inammatory models, Indian J. Physiol. Pharmacol. 23 (1979) 17.
[19] N.K. Khanna, B.R. Madan, Studies on the anti-inammatory activity of creatine,
Arch. Int. Pharmacodyn. Ther. 231 (1978) 340350.
[20] K.M. Leland, T.L. McDonald, K.M. Drescher, Effect of creatine, creatinine, and
creatine ethyl ester on TLR expression in macrophages, Int. Immunopharmacol.
11 (2011) 13411347.
[21] R.P. Vieira, R.C. Claudino, A.C.S. Duarte, A.B.G. Santos, A. Perini, H.C.C. Faria Neto, T.
Mauad, M.A. Martins, M. Dolhnikoff, C.R.F. Carvalho, Aerobic exercise decreases
chronic allergic lung inammation and airway remodeling in mice, Am. J. Respir.
Crit. Care Med. 176 (2007) 871877.
[22] R.A. Bassit, R. Curi, L.F. Costa Rosa, Creatine supplementation reduces plasma levels
of pro-inammatory cytokines and PGE2 after a half-ironman competition, Amino
Acids 35 (2008) 425431.
[23] Y.E. Taes, B. Marescau, A. DeVriese, P.P. DeDeyn, E. Schepers, R. Vanholder, J.R.
Delanghe, Guanidino compounds after creatine supplementation in renal failure
patients and their relation to inammatory status, Nephrol. Dial. Transplant. 23
(2008) 13301335.
[24] R.P. Vieira, A.C.S. Duarte, R.C. Claudino, A. Perini, A.B.G. Santos, H.T. Moriya, F.M.
Arantes-Costa, M.A. Martins, C.R.F. Carvalho, M. Dolhnikoff, Creatine supplementation exacerbates allergic lung inammation and airway remodeling in mice, Am. J.
Respir. Cell Mol. Biol. 37 (2007) 660667.
[25] R. Azeredo, J. Prez-Snchex, A. Sitj-Bobadilla, B. Fouz, L. Tort, C. Arago, A. OlivaTeles, B. Costas, European sea bass (Dicentrarchus labrax immune status and disease
resistance are impaired by arnine dietary supplementation, Plos One 10 (2015)
1371.
[26] M.G. Bemben, H.S. Lamont, Creatine supplementation and exercise performance:
recent ndings, Sports Med. 35 (2005) 107125.
[27] P.B. Gastin, Energy system interaction and relative contribution during maximal
exercise, Sports Med. 31 (2001) 725741.
[28] M.L. Field, Creatine supplementation in congestive heart failure, Cardiovasc. Res. 31
(1996) 174175.
[29] V.A. Saks, Y.O. Belikova, A.V. Kuznetsov, Z.A. Khuchua, T.H. Branishte, M.L.
Semenovsky, V.G. Naumov, Phosphocreatine pathway for energy transport: ADP
diffusion and cardiomyopathy, Am. J. Physiol. 261 (1991) 3038.
[30] M.J. Kushmerick, T.S. Moerland, R.W. Wiseman, Mammalian skeletal muscle bers
distinguished by contents of phosphocreatine, ATP, and Pi, Proc. Natl. Acad. Sci. U.
S. A. 89 (1992) 75217525.
[31] C. Bosco, J. Tihanyi, J. Pucspk, I. Kovacs, A. Gabossy, R. Colli, G. Pulvirenti, C.
Tranquilli, C. Foti, M. Viru, A. Viru, Effect of oral creatine supplementation on
jumping and running performance, Int. J. Sports Med. 18 (1997) 369372.
[32] B. Dawson, M. Cutler, A. Moody, S. Lawrence, C. Goodman, N. Randall, Effects of oral
creatine loading on single and repeated maximal short sprints, Aust. J. Sci. Med.
Sport 27 (1995) 5661.
[33] J.S. Volek, N.D. Duncan, S.A. Mazzetti, R.S. Staron, M. Putukian, A.L. Gmez, D.R.
Pearson, W.J. Fink, W.J. Kraemer, Performance and muscle ber adaptations to creatine supplementation and heavy resistance training, Med. Sci. Sports Exerc. 31
(1999) 11471156.
[34] R.B. Kreider, Effects of creatine supplementation on performance and training adaptations, Mol. Cell. Biochem. 244 (2003) 8994.
[35] J. Karimian, P.S. Esfahani, Supplement consumption in body builder athletes, J. Res.
Med. Sci. 16 (2011) 13471353.
[36] R.L. Terjung, P.M. Clarkson, E.R. Eichner, P.L. Greenhaff, P.J. Hespel, R.G. Israel, W.J.
Kraemer, R.A. Meyer, L.L. Spriet, M.A. Tarnopolsky, A.J. Wagenmakers, M.H. Williams, American college of sports medicine roundtable. The physiological and
health effects of oral creatine supplementation, Med. Sci. Sports Exerc. 32 (2000)
706717.
[37] S. Mihic, J.R. MacDonald, S. McKenzie, M.A. Tarnopolsky, Acute creatine loading increases fat-free mass, but does not affect blood pressure, plasma creatinine, or CK
activity in men and women, Med. Sci. Sports Exerc. 32 (2000) 291296.
[38] P.D. Grindstaff, R. Kreider, R. Bishop, M. Wilson, L. Wood, C. Alexander, A. Almada,
Effects of oral creatine supplementation on repetitive spring performance and
body composition in competitive swimmers, Int. J. Sport Nutr. 7 (1997) 330346.
[39] J.S. Volek, W.J. Kraemer, Creatine supplementation: its effect on human muscular
performance and body composition, J. Strength Cond. Res. 10 (1996) 200210.
[40] R.D. Burns, M.R. Schiller, M.A. Merrick, K.N. Wolf, Intercollegiate student athlete
use of nutritional supplements and the role of athletic trainers and dietitians in nutrition counseling, J. Am. Diet. Assoc. 104 (2004) 246249.
[41] R. Calfee, P. Fadale, Popular ergogenic drugs and supplements in young athletes,
Pediatrics 117 (2006) 577589.
[42] J.D. Metzl, E. Small, S.R. Levine, J.C. Gershel, Creatine use among young athletes, Pediatrics 108 (2001) 421425.
[43] M. Bamberger, The magic potion, Sports Illus. 88 (1998) 5861.
[44] J.R. Poortmans, M. Francaux, Adverse effects of creatine supplementation: fact or
ction? Sports Med. 30 (2000) 155170.
[45] J.P. Pearlman, R.A. Fielding, Creatine monohydrate as a therapeutic aid in muscular
dystrophy, Nutr. Rev. 64 (2006) 8088.
[46] T.A. McGuine, J.C. Sullivan, D.A. Bernhardt, Creatine supplementation in Wisconsin
high school athletes, Wis. Med. J. 101 (2002) 2530.
[47] M.A. Mason, M. Giza, L. Clayton, J. Lonning, R.D. Wilkerson, Use of nutritional supplements by high school football and volleyball players, Iowa Orthop. J. 21 (2001) 4348.
[48] T.A. McGuine, J.C. Sullivan, D.T. Bernhardt, Creatine supplementation in high school
football players, Clin. J. Sport Med. 11 (2001) 247253.
[49] J. Smith, D.L. Dahm, Creatine use among a select population of high school athletes,
Mayo Clin. Proc. 75 (2000) 12571263.
[50] M. Neves Jr., B. Gualano, H. Roschel, F.R. Lima, A. Lcia de S-Pinto, A.C. Seguro,
M.H. Shimizu, M.T. Sapienza, R. Fuller, A.H. Lancha Jr., E. Bonf, Effect of creatine
supplementation on measured glomerular ltration in postmenopausal women,
Appl. Physiol. Nutr. Metab. 36 (2011) 419422.
[51] E.S. Rawson, A.C. Venezia, Use of creatine in the elderly and evidence for effects on
cognitive function in young and old, Amino Acids 40 (2011) 13491362.
[52] B.T. Gufford, K. Sriraghavan, N.J. Miller, D.W. Miller, X. Gu, J.L. Vennerstrom, D.H.
Robinson, Physicochemical characterization of creatine N-methylguanidinium
salts, J. Diet. Suppl. 7 (2010) 240252.
[53] B. Gufford, E. Ezell, D. Robsinson, D. Miller, N. Miller, X. Gu, J. Vennerstrom, pHdependent stability of creatine ethyl ester: relevance to oral absorption, J. Diet.
Suppl. 10 (2013) 241251.
[54] M.J. Peral, M. Garca-Delgado, M.L. Calonge, J.M. Durn, M.C. De La Horra, T.
Wallimann, O. Speer, A.A. Ilundin, Human, rat, and chicken small intestinal
Na+/Cl/creatine transporter: functional, molecular characterization, and localization, J. Physiol. 545 (2002) 133144.
[55] M. Garca-Delgado, M.J. Peral, M. Cano, M.L. Calonge, A.A. Ilundin, Creatine transport in brush-border membrane vesicles isolated from rat kidney cortex, J. Am. Soc.
Nephrol. 12 (2001) 18191825.
[56] C. Guimbal, M.W. Kilimann, A Na+-dependent creatine transporter in rabbit brain,
muscle, heart and kidney. cDNA cloning and functional expression, J. Biol. Chem.
268 (1993) 84188421.
[57] M.N. Orsenigo, A. Faelli, S. De Biasi, C. Sironi, U. Laforenza, M. Paulmichl, M. Tosco,
Jejunal creatine absorption: what is the role of the basolateral membrane? J.
Membr. Biol. 207 (2005) 183195.
[58] V. Valayannopoulos, N. Boddaert, A. Chabli, V. Barbier, I. Desguerre, A. Philippe, A.
Afenjar, M. Mazzuca, D. Cheillan, A. Munnich, Y. de Keyzer, C. Jakobs, G.S.
Salomons, P. de Lonlay, Treatment by oral creatine, L-arginine and L-glycine in six
severely affected patients with creatine transporter defect, J. Inherit. Metab. Dis.
35 (2012) 151157.
[59] R.B. Kreider, Creatine supplementation in exercise and sport, in: J. Driskell, J.
Wolinsky (Eds.), Energy-yielding macronutrients and energy metabolism in sports
nutrition, CRC Press LLC, Boca Raton, FL 1999, pp. 213242.
Please cite this article as: L.A. Riesberg, et al., Beyond muscles: The untapped potential of creatine, Int Immunopharmacol (2015), http://
dx.doi.org/10.1016/j.intimp.2015.12.034
[88]
[89]
[90]
[91]
[92]
[93]
[94]
[95]
[96]
[97]
[98]
[99]
[100]
[101]
[102]
[103]
[104]
[105]
[106]
[107]
[108]
[109]
[110]
[111]
[112]
[113]
[114]
[115]
[116]
[117]
[118]
Please cite this article as: L.A. Riesberg, et al., Beyond muscles: The untapped potential of creatine, Int Immunopharmacol (2015), http://
dx.doi.org/10.1016/j.intimp.2015.12.034
10
[145] P.H. ME, A.Y. Chiu, M.C. Dal Canto, C.Y. Polchow, D.D. Alexander, J. Caliendo, A.
Hentati, Y.W. Kwon, H.X. Deng, et al., Motor neuron degeneration in mice that express a human Cu,Zn superoxide dismutase mutation, Science 264 (1994)
17721775.
[146] K.D. Kochanek, J.Q. Xu, S.L. Murphy, E. Arias, Mortality in the United States, 2013,
NCHS Data Brief National Center for Health Statistics, Centers for Disease Control
and Prevention, 178, US Dept of Health and Human Services 2014, pp. 18.
[147] H. Hara, R.M. Friedlander, V. Gagliardini, C. Ayata, K. Fink, Z. Huang, M. ShimizuSasamata, J. Yuan, M.A. Moskowitz, Inhibition of interleukin-1beta converting enzyme family proteases reduces ischemic and excitotoxic neuronal damage, Proc.
Natl. Acad. Sci. U. S. A. 94 (1997) 20072012.
[148] R.M. Friedlander, V. Gagliardini, H. Hara, K.B. Fink, W. Li, G. MacDonald, M.C.
Fishman, A.H. Greenberg, M.A. Moskowitz, J. Yuan, Expression of a dominant negative mutant of interleukin-1 beta converting enzyme in transgenic mice prevents
neuronal cell death induced by trophic factor withdrawal and ischemic brain injury, J. Exp. Med. 185 (1997) 933940.
[149] H. Hara, K. Fink, M. Endres, R.M. Friedlander, V. Gagliardini, J. Yuan, M.A.
Moskowitz, Attenuation of transient focal cerebral ischemic injury in transgenic
mice expressing a mutant ICE inhibitory protein, J. Cereb. Blood Flow Metab. 17
(1997) 370375.
[150] W.H. Zhang, X. Wang, M. Narayanan, Y. Zhang, C. Huo, J.C. Reed, R.M. Friedlander,
Fundamental role of the Rip2/caspase-1 pathway in hypoxia and ischemia-induced
neuronal cell death, Proc. Natl. Acad. Sci. U. S. A. 100 (2003) 1601216017.
[151] J.C. Martinou, M. Dubois-Dauphin, J.K. Staple, I. Rodriguez, H. Frankowski, M.
Missotten, P. Albertini, D. Talabot, S. Catsicas, C. Pietra, J. Huarte, Overexpression
of BCL-2 in transgenic mice protects neurons from naturally occurring death and
experimental ischemia, Neuron 13 (1994) 10171030.
[152] X. Jing, X. Wei, M. Ren, L. Wang, X. Zhang, H. Lou, Neuroprotective effects of
tanshinone I against 6-OHDA-induced oxidative stress in cellular and mouse
model of Parkinson's Disease through upregulating Nrf2, Neurochem. Res.
(2015) (E pub ahead of print Nov 4).
[153] Y.C. Chung, Y.S. Kim, E. Bok, T.Y. Yune, S. Maeng, B.K. Jin, MMP-3 contributes to
nigrostriatal dopaminergic neuronal loss, BBB damage, and neuroinammation
in an MPTP mouse model of Parkinson's disease, Mediat. Inamm. 2013 (2013)
370526.
[154] M. Salama, A. Ellaithy, B. Helmy, M. El-Gamal, D. Tantawy, M. Mohamed, H.
Sheashaa, M. Sobh, O. Arias-Carrin, Colchicine protects dopaminergic neurons
in a rat model of Parkinson's disease, CNS Neurol. Disord. Drug Targets 11
(2012) 836843.
[155] A. Mouatt-Prigent, Y. Agid, E.C. Hirsch, Does the calcium binding protein calretinin
protect dopaminergic neurons against degeneration in Parkinson's disease, Brain
Res. 668 (1994) 6270.
[156] W.P. Gai, J.C. Vickers, P.C. Blumbergs, W.W. Blessing, Loss of non-phosphorylated
neurolament immunoreactivity, with preservation of tyrosine hydroxylase, in
surviving substantia nigra neurons in Parkinson's disease, J. Neurol. Neurosurg.
Psychiatry 57 (1994) 10391046.
[157] J. Guan, R. Krishnamurthi, H.J. Waldvogel, R.L. Faull, R. Clark, P. Gluckman, Nterminal tripeptide of IGF-1 (GPE) prevents the loss of TH positive neurons after
6-OHDA induced nigral lesion in rats, Brain Res. 859 (2000) 286292.
[158] S. Tabrez, N.R. Jabir, S. Shakil, N.H. Greig, Q. Alam, A.M. Abuzenadah, G.A.
Damanhouri, M.A. Kamal, A synopsis on the role of tyrosine hydroxylase in
Parkinson's Disease, CNS Neurol. Disord. Drug Targets 11 (2012) 395409.
[159] M.P. van der Brug, A. Singleton, T. Gasser, P.A. Lewis, Parkinson's disease: from
human genetics to clinical trials, Sci. Transl. Med. 7 (2015) (205ps20).
[160] S.L. Kowal, T.M. Dall, R. Chakrabarti, M.V. Storm, A. Jain, The current and projected
economic burden of Parkinson's disease in the United States, Mov. Disord. 28
(2013) 311318.
[161] K.M. Gerecke, Y. Jiao, A. Pani, V. Pagala, R.J. Smeyne, Exercise protects against
MPTP-induced neurotoxicity in mice, Brain Res. 1341C (2010) 7283.
[162] S.N. Kim, A.R. Doo, J.Y. Park, H. Bae, Y. Chae, I. Shim, H. Lee, W. Moon, H. Lee, H.J.
Park, Acupuncture enhances the synaptic dopamine availability to improve
motor function in a mouse model of Parkinson's disease, Plos One 6 (2011),
e27566.
[163] M.G. Vuckovic, R.I. Wood, D.P. Holschneider, A. Abernathy, D.M. Togaski, A. Smith,
G.M. Petzinger, M.W. Jakowec, Memory, mood, dopamine, and serotonin in the 1methyl-4-phenyl-1,2,3,6-tetrahydropyridine-lesioned mouse model of basal ganglia injury, Neurobiol. Dis. 32 (2008) 319327.
[164] M. Bian, J. Liu, X. Hong, M. Yu, Y. Huang, Z. Sheng, J. Fei, F. Huang, Overexpression of
parkin ameliorates dopaminergic neurodegeneration induced by 1-methyl-4phenyl-1,2,3,6-tetrahydropyridine in mice, Plos One 7 (2012), e39953.
[165] E.D. Dean, L.M. Mexas, N.L. Cpiro, J.E. McKeon, M.R. DeLong, K.D. Pennell, J.A.
Doorn, V. Tangpricha, G.W. Miller, M.L. Evatt, 25-Hydroxyvitamin D depletion
does not exacerbate MPTP-induced dopamine neuron damage in mice, Plos One
7 (2012), e39227.
[166] N. Kadoguchi, S. Okabe, Y. Yamamura, M. Shono, T. Fukano, A. Tanabe, H.
Yokoyama, J. Kasahara, Mirtazapine has a therapeutic potency in 1-methyl-4phenyl-1,2,3,6-tetrahydropyridine (MTPT)-induced mice model of Parkinson's
disease, BMC Neurosci. 15 (2014) 79.
[167] A.L. McCormack, S.K. Mak, M. Shenasa, W.J. Langston, L.S. Forno, D.A. DiMonte,
Pathological modications of -synuclein in 1-methyl-4-phenyl-1,2,3,6tetrahydropyridine (MPTP)-treated squirrel monkeys, J. Neuropathol. Exp. Neurol.
67 (2008) 793802.
[168] K. Fifel, J. Vezoli, K. Dzahini, B. Claustrat, V. Leviel, H. Kennedy, E. Procyk, O. DkhissiBenyahya, C. Groner, H.M. Cooper, Alteration of daily and circadian rhythms following dopamine depletion in MPTP treated non-human primates, Plos One 9
(2014), e86240.
Please cite this article as: L.A. Riesberg, et al., Beyond muscles: The untapped potential of creatine, Int Immunopharmacol (2015), http://
dx.doi.org/10.1016/j.intimp.2015.12.034
11
[197] P. Lees, A.J. Higgins, Clinical pharmacology and therapeutic uses of non-steroidal
anti-inammatory drugs in the horse, Equine Vet. J. 17 (1985) 8396.
[198] N. LeFloc'h, D. Melchior, C. Obled, Modications of protein and amino acid metabolism during inammation and immune system activation, Livest. Prod. Sci. 87
(2004) 3745.
[199] P. Schiatti, D. Selva, E. Arrigoni-Martelli, L'edema localizzato da nystatin come
modello di inammazione sperimentale, Boll. Chim. Farm. 109 (1970) 3338.
[200] R.R. Razonable, M. Henault, H.L. Watson, C.V. Paya, Nystatin induces secretion of interleukin (IL)-1, IL-8,and tumor necrosis factor alpha by a toll-like receptordependent mechanism, Antimicrob. Agents Chemother. 49 (2005) 35463549.
[201] G. Kaithwas, D.K. Majumdar, Therapeutic effect of Linum usitatissimum (axseed/
linseed) xed oil on acute and chronic arthritic models in albino rats,
Inammopharmacology 18 (2010) 127136.
[202] G. Kaithwas, R. Gautam, S.M. Jachak, A. Saklani, Antiarthritic effects of Ajuga
bracteosa wall ex benth. in acute and chronic models of arthritis in albino rats,
Asian Pac. J. Trop. Biomed. 2 (2012) 185188.
[203] M. Choudhary, V. Kumar, P. Gupta, S. Singh, Investigation of antiarthritic potential
of Plumeria alba L. leaves in acute and chronic models of arthritis, Biomed. Res. Int.
2014 (2014) 474616.
[204] F.S. Ram, S.M. Robinson, P.N. Black, J. Picot, Physical training for asthma, Cochrane
Database Syst. Rev. 4 (2005), CD001116.
[205] K. Szentgothai, I. Gyene, M. Szcska, P. Osvth, Physical exercise program for children with bronchial asthma, Pediatr. Pulmonol. 3 (1987) 166172.
[206] A. Fanelli, A.L. Cabral, J.A. Neder, M.A. Martins, C.R. Carvalho, Exercise training on
disease control and quality of life in asthmatic children, Med. Sci. Sports Exerc.
39 (2007) 14741480.
[207] B.G. Nickerson, D.B. Bautista, M.A. Namey, W. Richards, T.G. Keens, Distance running improves tness in asthmatic children without pulmonary complications or
changes in exercise-induced bronchospasm, Pediatrics 71 (1983) 147152.
[208] M. Arborelius Jr., E. Svenonius, Decrease of exercise-induced asthma after physical
training, Eur. J. Respir. Dis. Suppl. Acta Paediatr. 136 (1984) 2531.
[209] I. Matsumoto, H. Araki, K. Tsuda, H. Odajima, S. Nishima, Y. Higaki, M. Tanaka, M.
Shindo, Effects of swimming training on aerobic capacity and exercise induced
bronchoconstriction in children with bronchial asthma, Thorax 54 (1999)
196201.
[210] J.M. Henriksen, T.T. Nielsen, Effect of physical training on exercise-induced
bronchoconstriction, Acta Paediatr. Scand. 72 (1983) 3136.
[211] J.M. Weiler, W.J. Metzger, A.L. Donnelly, E.T. Crowley, M.D. Sharath, Prevalence of
bronchial hyperresponsiveness in highly trained athletes, Chest 90 (1986) 2328.
[212] J.M. Weiler, T. Layton, M. Hunt, Asthma in United States olympic athletes who participated in the 1996 summer games, J. Allergy Clin. Immunol. 102 (1998) 722726.
[213] I. Helenius, T. Haahtela, Allergy and asthma in elite summer sport athletes, J. Allergy Clin. Immunol. 106 (2000) 444452.
[214] J.M. Weiler, E.J. Ryan, Asthma in United States Olympic athletes who participated
in the 1998 winter games, J. Allergy Clin. Immunol. 106 (2000) 267271.
[215] K. Ostrowski, T. Rohde, S. Asp, P. Schjerling, B.K. Pedersen, Pro- and antiinammatory cytokine balance in strenuous exercise in humans, J. Physiol. 515
(1999) 287291.
[216] B.K. Pedersen, A.D. Toft, Effects of exercise on lymphocytes and cytokines, Br. J.
Sports Med. 34 (2000) 246251.
[217] G.P. Tilz, W. Domej, A. Diez-Ruiz, G. Weiss, R. Brezinschek, H.P. Brezinschek, E.
Huttl, H. Pristautz, H. Wachter, D. Fuchs, Increased immune activation during
and after physical exercise, Immunobiology 188 (1993) 194202.
[218] A.I. Moldoveanu, R.J. Shephard, P.N. Shek, The cytokine response to physical activity and training, Sports Med. 31 (2001) 115144.
[219] J.R. MacKenzie, J. Mattes, L.A. Dent, P.S. Foster, Eosinophils promote allergic disease
of the lung by regulating CD4(+) Th2 lymphocyte function, J. Immunol. 167
(2001) 31463155.
[220] R.P. Vieira, A.C. Duarte, A.B. Santos, M.C. Medeiros, T. Mauad, M.A. Martins, C.R.
Carvalho, M. Dolhnikoff, Exercise reduces effects of creatine on lung, Int. J. Sports
Med. 30 (2009) 684690.
[221] S.C. Ferreira, A.C. Toledo, M. Hage, A.B. Santos, M.C. Medeiros, M.A. Martins, C.R.
Carvalho, M. Dolhnikoff, R.P. Vieira, Creatine activates airway epithelium in asthma, Int. J. Sports Med. 31 (2010) 906912.
[222] A.R. Brasier, The NF-kB regulatory network, Cardiovasc. Toxicol. 6 (2006) 111130.
[223] T.D. Gilmore, Introduction to NF-kB: players, pathways, perspectives, Oncogene 25
(2006) 66806684.
[224] H. Khalaf, J. Jass, P.-E. Olsson, Differential cytokine regulation by NF-kB and AP-1 in
Jurkat T-cells, BMC Immunol. 11 (2010) 2638.
[225] B. Beutler, TLRs and innate immunity, Blood 113 (2009) 13991407.
[226] A.J. Degraaf, Z. Zaslona, E. Bourdonnay, M. Peters-Golden, Prostaglandin E2 reduces
Toll-like receptor 4 expression in alveolar macrophages by inhibition of translation, Am. J. Respir. Cell Mol. Biol. 51 (2014) 242250.
[227] D. Braud, K.A. Maguire-Zeiss, Misfolded -synuclein and toll-like receptors: therapeutic targets for Parkinson's disease, Parkinsonism Relat. Disord. 18S1 (2012)
S17S20.
[228] M. Paola, S.E. Sestito, A. Mariani, C. Memo, R. Fanelli, M. Freschi, C. Bendotti, V.
Calabrese, F. Peri, Synthetic and natural small molecule TLR4 antagonists inhibit
motoneuron death in cultures from ALS mouse model, Pharmacol. Res. S10436618 (2015) 3000430009.
[229] W.M. Chu, Tumor necrosis factor, Cancer Lett. 328 (2013) 222225.
[230] R. Lyck, G. Enzmann, The physiological roles of ICAM-1 and ICAM-2 in neutrophil
migration into tissues, Curr. Opin. Hematol. 22 (2015) 5359.
[231] L.A. Silva, C.B. Tromm, G. Da Rosa, K. Bom, T.F. Luciano, T. Tuon, C.T. De Souza, R.A.
Pinho, Creatine supplementation does not decrease oxidative stress and inammation in skeletal muscle after eccentric exercise, J. Sports Sci. 1-13 (2013).
Please cite this article as: L.A. Riesberg, et al., Beyond muscles: The untapped potential of creatine, Int Immunopharmacol (2015), http://
dx.doi.org/10.1016/j.intimp.2015.12.034
12
Please cite this article as: L.A. Riesberg, et al., Beyond muscles: The untapped potential of creatine, Int Immunopharmacol (2015), http://
dx.doi.org/10.1016/j.intimp.2015.12.034