NSAIDs And Athletes: Part 1, Mechanisms And Prevalence Of Use

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This article is the first part in a series about non-steroidal anti-inflammatory drugs (NSAIDs) and athletics.  I hope that this information is helpful to you.  As always, please consult with your physician before taking medications of any kind.

NSAIDs, such as ibuprofen and naproxen, are commonly used in athletics.  Many people take these medications while training and before, during, and after competitions. Unfortunately, many people believe that the over-the-counter status of many NSAIDs and their widespread use means that these medications are safe.  There is a growing body of evidence, however, that NSAIDs may not be appropriate or safe for many athletes in many situations. This article will review the mechanism of action of NSAIDs (how they work) and the prevalence of use of NSAIDs in amateur and elite athletes.  Subsequent articles will review such issues as the dangers of these medications to the health of athletes, effects on performance, effects on healing, effects on adaptation, and reasons why people may learn to depend on NSAIDs.

Ibuprofen and other NSAIDs have a number of important biological effects. The following is a very complex diagram showing the role of ibuprofen (and other NSAIDs) in several biochemical pathways. Copyright to PharmGKB, permission has been given by PharmGKB and Stanford University to use the Ibuprofen Pathway Pharmacodynamics. Click on the image to go to the most up-to-date interactive version of the pathway and a detailed legend.

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The upper right part of the diagram shows one of the mechanisms for relief of pain, by affecting the cannabinoid receptors.  The lower right part of the diagram shows how NSAIDs can affect the nitric oxide pathway.  The left part of the diagram, however, is the focus of our discussion. It shows how NSAIDs block the actions of cyclooxygenase (COX) enzymes (COX-1 and COX-2, which are called PTGS1 and PTGS2 in this diagram).  These COX enzymes mediate the conversion of arachidonic acid from cell membranes into biologically active substances called prostaglandins. These prostaglandins have a wide variety of effects, including the promotion of pain, fever, and inflammation (the effects that NSAIDs aim to prevent), and protection of the stomach lining, promotion of normal kidney function, and improved aggregation of platelets to form clots (the effects that are usually undesirable to block).  This is the main pathway by which NSAIDs cause beneficial and harmful effects.  These harmful effects and others, and their clinical relevance to athletes, will be discussed in depth in an upcoming article in this blog.

In spite of the risk of side effects, many NSAIDs are easily obtainable over-the-counter.  I reviewed published data from a range of sources and I was very surprised by the prevalence of use of these medications by athletes across sports, levels of ability, genders, and age groups.

For example, in the 2008 Ironman triathlon in Florianopolis, Brazil, approximately one quarter of athletes (n=327) participated in a survey about the use of NSAIDs.  59.9% reported using NSAIDs in the previous three months.  Of these athletes who had used NSAIDs, 25.5%, 17.9%, and 47.4% reported consuming NSAIDs the day before, immediately before, and during the race.  In other words, about a quarter of these Ironman participants used NSAIDS DURING THE RACE.  48.5% of NSAID users did so without a medical prescription.

In study of self-administered questionnaires given to 681 male high school football players, 75% had used NSAIDs in the past 3 months and 15% were daily users.

In FIFA international soccer, team physicians reported that 30.7% of female athletes were taking NSAIDs within 72 hours of matches.  In the male under-17 and under-20 groups, 17.3% and 21.4%, respectively, had taken NSAIDs within 72 hours of matches.

In another survey of the use of NSAIDs in international soccer, team physicians reported that more than half of adult male players used NSAIDs within 72 hours of matches.  Up to one third of the players  who took NSAIDs used them before every match, regardless of whether they took the field or not.

In a survey of data taken from doping control forms and drug exemption forms from the 2004 Athens Summer Olympic Games, 11.1% of athletes used NSAIDs.

With regard to elite track and field athletes, a review of doping control forms, which were submitted for 12 International Association of Athletics Federations World Championships and 1 out-of-competitions season, was performed.  The per-athlete use of NSAIDs was 0.27 (note that some athletes used more than one NSAID at a time, so the rate of use was not 27%). This use was higher in power and sprint disciplines than in middle- and long-distance runners.

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In a study of amateur marathon runners, 3913 (of 7043 total) participants in the Bonn marathon in 2010 returned questionnaires about the use of analgesics immediately before the marathon.  49% of these participants reported using analgesics immediately before the race. The overwhelming majority of the analgesics used were NSAIDs.  Interestingly, 54% were taken without a prescription.  Also, significantly more women than men took analgesics (61% vs 42%). Of all respondents to the survey, 93% stated that they were not informed about the risks of using analgesics in connection with endurance sports.

The prevalence data between these studies is not easy to compare, since the studies drew data from different sources.  These sources, as described, above, included questionnaires of athletes, surveys of team physicians, and doping control submissions.  Furthermore, data was grouped in different ways.  For example, genders were not divided for the Ironman data and some other studies focused broadly on the 72 hours before competition. Nonetheless, it is clear that athletes, irrespective of sport, level of ability, gender, or age, use NSAIDs frequently. Furthermore, where data was available it appears that roughly half of athletes who use NSAIDs do so without the supervision of their physicians.

NSAIDs, as discussed, above, are potent medications with known beneficial and detrimental effects. These drugs are widely used by athletes.  The next article in this series will explore, in much more detail, the dangers of NSAIDs to athletes.

Stay tuned!  Be safe.

References:

Burian M and Geisslinger G. Cox-dependent mechanisms involved in the antinociceptive action of NSAIDs at central and peripheral sites. Pharmacol Ther. 2005 Aug;107(2):139-154.

Gorski T, Cadore EL, Pinto SS, et al. Use of NSAIDs in triathletes: prevalence, level of awareness and reasons for use. Br J Sports Med. 2011;45:85-90.

Kuster M, Renner B, Oppel P, et al. Consumption of analgesics before a marathon and the incidence of cardiovascular, gastrointestinal and renal problems: a cohort study. BMJ Open. 2013;3:e002090.

Mazaleuskaya LL, Theken KN, Gong L, et al. “PharmGKB summary: ibuprofen pathwaysPharmacogenetics and genomics (2014).

Tscholl P, Alanso JM, Dolle G, et al. The use of drugs and nutritional supplements in top-level track and field athletes. Am J Sports Med. 2010 Jan;38(1):133-140.

Tscholl P, Feddermann N, Junge A, et al. The use and abuse of painkillers in international soccer: data from 6 FIFA tournaments for female and youth players. Am J Sports Med. 2009 Feb;37(2):260-265.

Tscholl PM, Vaso M, Weber A, et al. High prevalence of medication use in professional football tournaments including the World Cups between 2002 and 2014: a narrative review with a focus on NSAIDs. Br J Sports Med. 2015 May;49(9):580-582,

Tsitsimpikou C, Tsiokanos A, Tsarouhas K, et al. Medication use by athletes at the Athens 2004 Summer Olympic Games. Clin J Sport Med. 2009 Jan;19(1):33-38.

Warner DC, Schnepf G, Barrett MS, et al. Prevalence, attitudes, and behaviors related to the use of nonsteroidal anti-inflammatory drugs (NSAIDs) in student athletes. J Adolesc Health. 2002 Mar;30(3):150-153.

Photo Credit: N08/2969620211/”>reallyboring via Compfight cc

3 thoughts on “NSAIDs And Athletes: Part 1, Mechanisms And Prevalence Of Use

  1. Pingback: NSAIDS And Athletes: Part 2 | An Allergist/Immunologist's Guide to Living Well

  2. Pingback: NSAIDs And Athletes: Part 3, Effects During Endurance Racing Events | An Allergist/Immunologist's Guide to Living Well

  3. Pingback: NSAIDs And Athletes: Part 4, Effects Of NSAIDs On Exercise-Induced Pain And Inflammation | An Allergist/Immunologist's Guide to Living Well

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