NSAID Use in Endurance Events: a Cross-Sectional Study of NSAID Use in Two Swedish Multisport Cup Races
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NSAID use in endurance events: A cross-sectional study of NSAID use in two Swedish Multisport Cup Races Emma Wichardt Supervised by: Karin Henriksson -Larsén C. Mikael Mattsson Emma Wichardt Sports medicine unit Department of surgery and perioperative sciences Umeå University 901 87 Umeå Phone: +46 90 785 48 13 Fax: +46 90 13 56 92 E-mail: [email protected] 1 Table of contents ABSTRACT ............................................................................................................................................. 3 INTRODUCTION ................................................................................................................................... 4 Adverse effects in conjunction with NSAID use .................................................................................................. 4 NSAID use in sports ............................................................................................................................................ 4 Objective ............................................................................................................................................................ 6 METHOD ................................................................................................................................................. 6 Stockholm Adventure Race – STAR .................................................................................................................... 6 Femmans Multisport Race ................................................................................................................................. 6 RESULTS ................................................................................................................................................. 7 DISCUSSION ........................................................................................................................................... 7 CONCLUSION ......................................................................................................................................... 9 REFERENCES ...................................................................................................................................... 11 2 Abstract Non-doping classified medicines are to a large extent used by athletes to treat injuries, cure illnesses and obtain a competitive edge. NSAIDS are frequently prescribed to athletes to suppress inflammation and pain, yet one in five athletes report adverse effects after such use. Objective: To examine the frequency of NSAID use in adventure racing and specifically study whether the length of a race may influence the extent of NSAID use. Further, the study also assesses the reasons for NSAID use and possible adverse effects. Method: A cross-sectional study of two Swedish Multisport Cup races. 59 racers participated in the study. Result: 1 racer (1.7 %) used NSAID during one of the two races. A total of 42.4 % (n=25) have occasionally used NSAIDs during or between races. 23.7 % (n=14) sometimes use NSAIDs during races. 12.0 % (n=3) of the 25 athletes that sometimes use NSAIDs reported adverse effects. Reasons for NSAID use were diverse. The most common reason was to reduce pain in general during longer races (n=8). Conclusion: Results show a clear difference in NSAID use between the shorter races studied here and the longer previously studied adventure race, with NSAID use being much more common in the latter (1.7 % vs. 30 %). NSAID use in longer races is at approximately the same level as NSAID use in other endurance events. Based on the reasons for NSAID use stated in this study, it is clear that athletes have a very limited knowledge and awareness regarding effects, indications for use, and possible adverse effects of the medicine. 3 Introduction Non-doping classified medicines are to a large extent used by athletes to treat injuries, cure illnesses and obtain a competitive edge.(1) NSAIDs (non-steroidal anti-inflammatory drugs) are according to two separate studies the second most commonly used drugs by athletes, behind vitamins (1) or anti- allergic medicines.(2) They are frequently prescribed to athletes to suppress inflammation and pain after soft-tissue injuries and after overuse injuries.(3-6) Yet, one in five athletes report adverse effects in conjunction with NSAID use.(2) Adverse effects in conjunction with NSAID use All NSAIDs, due to their inhibition of prostaglandin synthesis, can have a wide range of adverse effects.(7-8) 19.2 % (n=42) of Finnish elite athletes using NSAIDs reported drug-related adverse effects. Most common were central nervous system-related (11.0 %) and gastrointestinal-related adverse effects (8.7 %).(2) 18.3 % of the during-race-users in the Brazil Ironman Triathlon reported adverse effects, of which gastro-intestinal problems (7.5 %) were the most common.(9) NSAID- induced gastro-intestinal toxicity is also the most common adverse drug effect reported in the USA in the general population.(10) NSAIDS have for long been thought to be a risk factor for hyponatremia.(11) This was shown in a study of the 2004 New Zealand Ironman Triathlon, which was the first study to show that NSAID use is associated with an increased incidence of hyponatremia (p<0.001).(12) The authors of that study found that NSAIDs affect renal function during exercise, in line with another similar study.(13) Renal damage, secondary to exercise-induced rhabdomyolysis in athletes taking NSAIDs, has been reported in several studies.(14-17) The risk of exertional rhabdomyolysis leading to renal failure has been shown to be greatly enhanced when consuming NSAIDs. Seven out of nine runners suffering from acute renal failure from exertional rhabdomyolysis during a marathon race had taken NSAIDs.(18) Four cases of acute renal failure were reported after an ultra-marathon, and all four had ingested NSAIDs.(19) Many athletes with minor injuries do not take enough time off training or competition to allow proper healing.(1, 20-21) Instead they begin to treat their problems with NSAIDs and continue to exercise. But there is increasing evidence that NSAIDs may have a deleterious effect on the regeneration process in healing, and that the inflammation that NSAIDs are aiming to decrease is in fact necessary for adequate tissue repair.(21-23) NSAID use in sports Because of the risk for adverse effects in athletes using NSAIDs during exercise, it is of interest to study the extent of NSAID use in different sports. Several studies of NSAID use has been conducted during the Olympic Games, and in other unselected populations of athletes. Berglund et al. (24) studied the use of NSAIDs in Swedish Olympic athletes during the games in Atlanta in 1996, Nagano in 1998 and Sydney in 2000. In the Atlanta games, 11.5% of these athletes used NSAIDs, and in Sydney and Nagano the numbers were 7.6 % and 6.7 % respectively. They estimated the NSAID use to be 6-10 times higher in Swedish Olympic athletes than in the general Swedish population of the same age. Among Canadian athletes, NSAID use was 33.0 % and 38.0 % respectively in the Atlanta and Sydney games.(25) 4 At the Sydney games, athletes of all nationalities selected for doping control were asked “what medications have you taken in the past three days?” All prescription drugs, over-the-counter medications and other substances like vitamins were to be included in the answers. 2758 athletes responded to the question. Of those, 2167 had taken some kind of medication, and 706 (25,6%) had taken NSAIDS, second only in frequency to vitamin use.(1) The only study that has compared the use of NSAIDs in elite athletes to that of an age-matched control from the general population is that of Alaranta et al.(2) They studied all Finish elite athletes financially supported by the National Olympic Committee (n=494) and found that 49.1 % (n=219) had used physician-prescribed NSAIDs in the previous 12 months. 2.0 % reported daily use and 10.8 % reported monthly use. During the previous seven days before the study, 8.1 % of the athletes, and 2.7 % of the controls had used NSAIDs. In the endurance athletes’ category, the same number was 4.6%. A study from Belgium analyzed data from 18,645 doping control forms gathered for the years 2002- 2005. The prevalence of NSAID use three days before competition varied between 12-13 % for each year.(26) They found that use of NSAIDs was most prevalent in athletics and ball sports, with 20-30 % use in volleyball and 19-25 % in soccer each year, compared to only 4-6 % in cycling. A high usage among ball sports players was also found in two studies of soccer players. In one study from Italy, 93 % of the players in the major leagues reported a high use of NSAIDs.(27) In a study of American student soccer players, 75 % reported having used NSAIDs in the previous 3 months, and 15 % were daily users.(28) A few endurance events have been studied in relation to NSAID use. During the 2004 New Zealand Ironman Triathlon, the incidence of NSAID use 24 hours prior to race finish was 30% (100/333 athletes).(12) 20 % of the participants in the Kepler Challenge, a New Zealand ultra mountain-run, had used NSAIDs in the 24 hours before and during the race, and 15 % had used COXIBs (selective cyclooxygenase-2 inhibitors.(29) Gorski et al. (9) studied the prevalence of NSAID use and the level of awareness regarding NSAID use during the 2008 Brazil Ironman Triathlon. A sample of athletes (327 of 1250) answered a questionnaire after the race about NSAID consumption, reason for use and adverse