The use of creatine supplementation continues to be a hotly debated and relevant topic for health care professionals, amid its widespread use among young people and the mass of research with inconclusive or questionable outcomes. While the argument that creatine is an effective anaerobic ergogenic aid has a wealth of evidence, the case for the safety of its long term use does not. This fact is worrisome given the cavalier manner in which many use the supplement, as considerations of genetic predispositions to kidney disease, underlying occult or known disease states, or even metabolically competing medications are often excluded from the decision of whether, how much and for how long to use the creatine supplement. While evidence to date does not suggest a widespread pattern of severe side effects from its use, the research is silent regarding risks in the context of disease, such as impaired glomerular filtration. In an era where the burden of proof lies with the health care professional, who operates under the principle of evidence based medicine, physicians should work to communicate this lack of clarity, to urge caution and to demand more comprehensive research.