Prophylactic misuse and recommended use of
non-steroidal anti-inflammatory drugs by athletes
Stuart J Warden Br. J. Sports Med.
2009;43;548-549; originally published online 9 Jan 2009; doi:10.1136/bjsm.2008.056697
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British Journal of Sports Medicine
selectively of the agent.8–10 As the adversegastrointestinal and cardiovascular effects
associated with NSAIDs become morepronounced with increased duration ofuse, athletes risk serious side effects by
using NSAIDs prophylactically for pro-longed periods. This is further com-
approximately 10% of those who useNSAIDs take up to five different com-pounds concomitantly.3 4 11
terms of blocking pain before it occurs.5
activities such as each player touching a
winning streak. These practices are rela-
athletes to inadvertently allow pathology
petition anxiety, but a concerning ritual
the prophylactic use of non-steroidal anti-
the synthesis of the extracellular matrix
isozymes and, in particular, the inhibition
the rate-limiting step in the formation of
synthesis immediately before or following
mechanical stimuli.13 14 Athletes who reg-
have reduced tissue adaptation to prevail-
ing loads potentially predisposing them to
is unsafe. In addition to participating in
lactic use of NSAIDs has the potential to
subsequent tissue repair following micro-
diovascular functions. As a result, NSAID
athletic endeavours, but more recent data
suggest athletes misuse their open accessto NSAIDs. Tscholl and colleagues4recently reported in this journal that23% of top-level male football playersused NSAIDs in two out of three matchesduring the 2002 and 2006 Fe´de´rationInternationale de Football AssociationWorld Cup tournaments and that morethan 10% of players took NSAIDs beforeevery match. These data suggest thatmany athletes use NSAIDs prophylacti-cally and presumably for prolonged peri-ods. This hypothesis is supported by thefinding that high-school level Americanfootball players who take NSAIDs daily
Correspondence to: Dr Stuart J Warden, Departmentof Physical Therapy, School of Health and RehabilitationSciences, Indiana University, 1140 W Michigan St, CF-
Decision tree for the prescription of non-steroidal anti-inflammatory drugs (NSAIDs) to
326, Indianapolis, IN 46202, USA; [email protected]
athletes with an acute or chronic musculoskeletal injury.
Rostom A, Dube C, Lewin G, et al. Nonsteroidal anti-
inflammatory drugs and cyclooxygenase-2 inhibitors
for primary prevention of colorectal cancer: a
be as effective as NSAIDs at treating acute
systematic review prepared for the U.S. Preventive
musculoskeletal pain.23 Alternatively, at-
Services Task Force. Ann Intern Med2007;146:376–89.
risk athletes may be offered the option of
Tscholl P, Feddermann N, Junge A, et al. The use
and abuse of painkillers in international soccer: data
that regular use of NSAIDs reduces injury
from 6 FIFA Tournaments for female and youth
gastroprotection.9 Ultimately, there is no
players. Am J Sports Med 2009;37:260–5.
Warden SJ. Cyclooxygenase-2 inhibitors (COXIBs):
athlete. While ‘‘absence of evidence is not
beneficial or detrimental for athletes with acute
evidence of absence’’, there is sufficient
musculoskeletal injuries? Sports Med 2005;35:271–83.
concern regarding potential side effects of
Forwood MR. Inducible cyclo-oxygenase (COX-2)
NSAIDs to warrant their judicious use.
mediates the induction of bone formation bymechanical loading in vivo. J Bone Miner Res
Mackey AL, Kjaer M, Dandanell S, et al. The
adjuncts for the alleviation of acute pain
influence of anti-inflammatory medication on exercise-
and inflammation during rehabilitation.
induced myogenic precursor cell responses inhumans. J Appl Physiol 2007;103:425–31.
Simon AM, Manigrasso MB, O’Connor JP. Cyclo-
oxygenase 2 function is essential for bone fracture
healing. J Bone Miner Res 2002;17:963–76.
Cohen DB, Kawamura S, Ehteshami JR, et al.
World Anti-Doping Agency. The 2009 Prohibited
Indomethacin and celecoxib impair rotator cuff
List: International Standard. Montreal, Canada, 2008.
NSAIDs for clinical indications (ie, inju-
Alaranta A, Alaranta H, Helenius I. Use of
prescription drugs in athletes. Sports Med
ries, rather than prophylactically) is the
Ferry ST, Dahners LE, Afshari HM, et al. The effects
observation that their negative effect on
of common anti-inflammatory drugs on the healing rat
Corrigan B, Kazlauskas R. Medication use in athletes
patellar tendon. Am J Sports Med 2007;35:1326–33.
selected for doping control at the Sydney Olympics(2000). Clin J Sport Med 2003;13:33–40.
diminished if the NSAID is taken after the
Tscholl P, Junge A, Dvorak J. The use of medication
cyclooxygenase-2-specific inhibitor, delays skeletal
fact (ie, after exercise) rather than pro-
and nutritional supplements during FIFA World Cups
muscle healing by decreasing regeneration andpromoting fibrosis. Am J Pathol 2005;167:1105–17.
phylactically.20 If an athlete wants to use
2002 and 2006. Br J Sports Med 2008;42:725–30.
Warden SJ, Avin KG, Beck EM, et al. Low-intensity
Warner DC, Schnepf G, Barrett MS, et al.
Prevalence, attitudes, and behaviors related to the
pulsed ultrasound accelerates and a nonsteroidal anti-
use of nonsteroidal anti-inflammatory drugs (NSAIDs)
inflammatory drug delays knee ligament healing.
in student athletes. J Adolesc Health 2002;30:150–3.
indeed indicated (fig 1), its use should be
Ekman EF, Ruoff G, Kuehl K, et al. The COX-2 specificinhibitor valdecoxib versus tramadol in acute ankle
prostaglandin synthesis with NS-398 has different
restricted to the minimal dose and for the
sprain: a multicenter randomized, controlled trial.
effects on endocortical and periosteal bone formation
induced by mechanical loading. Calcif Tissue Int
Buvanendran A, Kroin JS, Tuman KJ, et al.
Gerstenfeld LC, Al-Ghawas M, Alkhiary YM, et al.
Effects of perioperative administration of aselective cyclooxygenase 2 inhibitor on pain
Selective and nonselective cyclooxygenase-2
symptoms (ie, active swelling and resting
management and recovery of function after knee
inhibitors and experimental fracture-healing.
replacement: a randomized controlled trial. JAMA
Reversibility of effects after short-term treatment.
during this stage, NSAIDs reduce pain and
J Bone Joint Surg Am 2007;89:114–25.
Jones R, Rubin G, Berenbaum F, et al.
Simon AM, O’Connor JP. Dose and time-dependent
Gastrointestinal and cardiovascular risks of
effects of cyclooxygenase-2 inhibition on fracture-
nonsteroidal anti-inflammatory drugs. Am J Med
healing. J Bone Joint Surg Am 2007;89:500–11.
Woo WW, Man SY, Lam PK, et al. Randomized
Mitchell JA, Warner TD. COX isoforms in the
double-blind trial comparing oral paracetamol and oral
cardiovascular system: understanding the activities of
nonsteroidal antiinflammatory drugs for treating pain
Athletes with a history of side effects or
non-steroidal anti-inflammatory drugs. Nat Rev Drug
after musculoskeletal injury. Ann Emerg Med
risk factors for side effects with NSAIDs
Silica, Nature’s Surgeon Experts believe higher blood serum levels lead to hardening of the arteries, which can cause heart attacks. The authors of the study called for We all want to be beautiful, live longer, be a rethink on giving people calcium supplements healthier and feel better, but how do you know for bone health. "Serum calcium levels have what to do to achieve this? How of
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