NSAIDs during a race?

NS/AIDS interfere with kidney functions and can lead to dehydration. You'd be better off with Tylenol, which isn't/doesn't.

Edited by the bear 2005-06-12 9:10 PM

The answer to your back problem will not be solved with NSAID's. If anything, it will most likely make the injury/problem progressively worse. What you are doing is a form of doping. NSAID's are a recovery aid... not intended as performance aide by reducing/masking pain.

Advil, Aleve (or other OTC equivalents) plus Bextra, Celebrex (prescription versions of NSAID's) are all NSAID's. Bextra and Celebrex are NSAID's whose specific advantage is that it doesn't upset the stomach like other NSAID's. This is accomplished by only inhibiting the COX II enzyme of the Coclo-oxygenase - COX group (i.e., COX I - needed for stomach lining and COX II - not as crucial to stomach lining protection). COX enzymes cause inflammation, swelling and other muscle related problems. Reducing COX II enzymes results in reduction in inflammation without reducing COX I enzymes (...the "lining protecting" enzymes)

It's only serious problems related to all NSAID's (OTC or Prescriptions - Including Advil or Aleve) and endurance sports is Hyponatremia. This is a result of abnormal stress placed on the kidneys as a result of reduced blood flow to the kidney resulting in renal failure caused by ALL COX inhibiter drugs such as Celebrex (including OTC such as aspirin, Tylenol and ibuprophren - they too inhibit COX enzymes (i.e., both COX I and COX II while Celebrex only inhibits COX II).

Advil or Aleve (or prescription products similar to Celebrex such as Vioxx and Bextra) is safe to take provided it is taken for the right reason. The correct reason is using it for recovery purposes. The incorrect reason is for performance enhancement called doping (such as using during an endurance event as you indicated).

Hyponatremia and the resulting kidney damage is usually a result of doping. Doping is a process by which you take the drug to enhance your performance. Toxicity typically occurs if the drug (or any NSAID - OTC or prescription) is taken prior to (i.e., 24-48 hrs. before and event - dependent on dosage amount and time on dosage) or during a race.

There has been no study to sight more specifics than that and it's been noted that the reason's for serious toxic side effects occur are not consistent. By that I mean, someone could have been taken NSAID's for many years under many conditions and have no harmful side effects. Then, for some unknown reason the toxicity of the drugs take effect and they have permanent kidney damage. In essence, using NSAID's for the purpose of masking pain or enhance performance is a form of Russian Roulette with the kidney (and, to a lesser extent the liver also).

The proper use of NSAID's is for recovery. Using NSAID's under normal conditions (of which, they were intended and tested) will have minimal side effects (unless it's prolong and consistent usage - such as women who have used it for many years to sedate menstrual cramps have experienced). The key is to take the drug during times when the kidney's are not being placed under unusual stress. The drugs works slowly and will be in the system for longer periods of time (hence, the 24-48 hrs. period of non-use prior to race to reduce it's potential toxicity).

Additional irony is that many OTC products (such as Tylenol and Aspirin - potentially hepatotoxic drugs) are actually more toxic to the liver (and kidney) than prescription NSAID's. This is because many were introduced before tougher standards were introduced. In fact, they can cause internal bleeding as a result of their ability to reduce both COX I and COX II which are important to platelet functions. In particular the COX II block production of prostaglandin. These are necessary for the regulation of blood flow through the kidneys. When blood fails to reach the kidney, it can't process the fluids (simulating dehydration). The results is Hyponatremia... not because you drank to much and diluted the bodies minerals... but, because the body can't process the fluids required to remove the excess fluids.

Additionally, the symptoms of Hyponatremia and Dehydration are very similar. The only notable difference is vomiting (and for some reason females are more susceptible). Unfortunately, the common treatment for Dehydration is introduction of fluids via IV's. This is bad news if you are actually suffering form Hyponatremia. Increasing fluids only compounds the problems (i.e., Saline solution in the IV does not increase the mineral content as one my expect - remember, the problem is PROCESSING the fluids and minerals - NOT more fluids we/ or w/out sodium, etc.). Increasing fluids can result in serious problems that can result in "drowning in your own fluids" (to be a tad bit overly dramatic - but still a possibility).

This means if you take NSAID's and race and have symptoms of severe dehydration... make sure that dehydration is the problem and not Hyponatremia. If in doubt, tell the medical personal that you have been on NSAID's (including Aspirin, Tylenol, Celebrex, Aleve etc.) and how much and when you took them (specially if you took them before or during the race). If you have vomiting symptoms - think Hyponatremia and get to a specialists - it's is possible that EMT's or Doctors (for that matter) can misdiagnose and confuse these two problems - Dehydration and Hyponatremia.

Well, that's the short version regarding ALL NSAID's... I know this is a long post but hopefully helpful. BTW, if you want references see below.

In one sentence, your use of Aleve is not advisable and can be dangerous... exactly how dangerous is not exactly understood. There are no standardized benchmarks that can determine when kidney damage can result from taking NSAID's while the body is under dehydration-like stress. It's sort of a Russian Roulette approach to solving inflammation problems that are probably a result of poor training methodology. Inflammation is indicative of many issues in which NSAID's are intended to alleviate and not mask. Being on a kidney machine for life vs. a pill to make me "think" I'm improving my athletic performance is not a good choice regardless of what the odds may be of that occurring.

What are the odds of serious toxicity side effects from mis-using NSAID's? The verdict is out with regard to certainty... but, the non-use of NSAID's during training or racing is 100% certain that no toxic side effects will occur. The key is using NSAID's correctly... not, avoiding the use of NSAID's. From what you described, you are not using them correctly and leaves the potential for serious kidney damage as a possibility.


FWIW Joe Moya

Marathoner's and Hyponatremia:

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMe...

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMe...

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMe...

Interesting study also, but a bit inconclusive:

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMe...

Non-athletic induced toxicities as well:


http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMe...

General information about NSAID's

http://www.backandneckpain.com.au/drugs.htm

Athletes and NSAID's

http://www.hoopskillz.homestead.com/NSAID.html

Note of relationship between NSAID's and Hyponatremia (good general article):

http://my.webmd.com/content/article/18/1676_52500.htm?lastselectedg...

(side note: you may need to cut and past this link - seems the sight may not allow brackets to included in a link.)

Interesting note... the article notes that Tylenol to be considered safe... this is a misconception (noted by many health experts). What they should say is that Tylenol is SAFER (but is not safe). It's potential side effects will affect the Liver instead of the Kidneys. Whether it's the Kidney or the Liver, I prefer not to draw the line. The key added element that is left out is alchohol. If you take Tylenol (or any NSAID) and decide to drink a beer after a event, you dramatically increase your potential for kidney problems (specially with Tylenol - the studies that varified this were done with alchoholics some years ago).

These are but a few references, but should be sufficient to help you with your interests.

WOW, I'll try to keep mine short.  NSAID's can cause dehydration through thinning blood and decreasing blood flow.  Decreasing blood means less oxygen to the working muscles that need oxygen.  Plus you are just hiding pain that is telling you something is wrong.  I would get the back looked at and possibly consider some PT to correct the problem.  If you need to take something, Tylenol would be your best bet, but again, just masking the pain.

Thanks for the detailed info. I have been taking NSAIDs for years for my arthritis and in recovery form my knee replacements. I have recently been getting good enough that I have dropped the Aleve and went to Tylenol on an as needed basis (for stiffness and post workout pain). I will certianly give this all a good thinking over.

This isn't an injury issue.  I've been running for 15 years and lower back pumps have been with me all along to some degree.  It's just that they tend to be especially annoying when I run off of a 40+ mile hard ride.  I can usually run through it but it may take 20+ minutes which is mentally tough, especially being 3+ hours into a workout/race.  Once I get through and the tightness goes away I don't have any soreness or discomfort during the rest of the run or at any point after...no sign of any back soreness the next day.  I usually take Excedrine (aspirin, acetaminophen, caffeine) for headaches but I figured the asprin might thin my blood and wouldn't be the best choice for during a race.

So, is it actually illegal to take any kind of pain medication during a race?  The info above considers this "doping" although I find it hard to believe that anyone who tries to ease their suffereing with a couple Advil during a long race is subject to penalties or disqualification.

I had a quick look through the literature that was sited in the long post above, and I did a quick medline search myself and I have to say, I am not convinced that popping a couple of pills poses a serious risk to the majority of us. I concur that there is good evidence for altered renal function and this is not a good thing, and there also seems to be a link between their use and hyponatremia, but I didn't see much evidence to suggest that this latter link was a serious risk in athletes. In one study (not listed here) the use of NSAIDS was the same between hyponatremic and non-hyponatremic marathoners. In one of the studies listed here they discuss 7 hyponatremic marathoners who were NSAID users who collapsed at the end of the marathon. They did not talk about non-NSAID users who were hyponatremic. I admit to just browsing the literature due to the fact that I am at work and shouldn't be reading BT right now. So I may have missed some important points.

If you are a sprint or olympic triathlete, I do not think you are at much of an increased risk for these potential problems unless you have some underlying kidney disorder. Marathoners are always going to be at increased risk of dehydration, hyponatremia etc by virtue of the time spent exerting themselves. I think their risk is much higher than most of ours.

The real issue is that you are taking drugs to mask pain so you can continue to exercise. This is never a good thing. If you absolutely must continue to do this, I would suggest using a topical analgesic (look for things that contain salicylic acid or salicylates) which shouldn't affect your gut or kidneys to the same degree as pills. In the meantime, figure out what is wrong with your back. Try some extra stretching and strengthening.

These are just my opinions and I am not endorsing pill-popping. I suggest you read the literature yourself to make up your own mind about these things.

I agree...this isn't something I'm considering on a regular basis.  For workouts I just work through the discopmfort because I know it will likely go away eventually and slowing my pace or taking a quick break to loosen up a little is fine.  But during a race I'd be pushing hard regardless...I'd just have to suck up the pain which is more mentally tiring than anything.

Interested to hear if there is anything official in the rules about using OTC drugs during competition though...is it officially "doping"?

"Interested to hear if there is anything official in the rules about using OTC drugs during competition though...is it officially "doping"?"

No - unless it is under the list of banned substances.

It's funny how the term doping can be taken with such negative implications. When, doping is generic term for using any form of drug to improve performance. Caffeine is an example of doping (IMHO), but doesn't carry the potential toxicity that NSAD's can...

As for triathlons and NSAID's... the studies indicate the potential toxicity... they do not define the probability. Also, when you look at the studies more closely you will not they are extreme distances and do not involve shorter distance triathlons.

There can be drawn no conclusion as to whether or not distance is a correlative factor to Hyponatremia since no comparitive studies exists. However, I think it would be safe to ASSUME that the shorter distances carry a lower probability of having toxicity like implications regarding NSAID's. That being said, I think it would also more inclusive to say the dosage and length of time under medication are crucial elements that could also drastically change this probability.

The bottom line, it would be best to use some common sense. Avoid taking NSAID's if possible during situations where the kidney is put under stress. This would be specially true during training sessions or races. The proper time to use medications is during recovery. And, try and find the root cause of the problem... this will be the best solution.

And, Quite honestly...your back issue sounds very simular to my situation... for many years I "worked" my way throught it... eventually, the pain gradually became more severe. So, I finally went to a doctor... it was a herniated disk. It probably didn't start out as a herniated disk... but, through my neglect it became a serious health issue.

Most medical problems can be solved without resorting to NSAID useage as a method to help "push hard" by simply getting a proper diagnosis and physical therapy. As for myself, I hardly ever use NSAID's any more... instead, I have develop a training program designed around my limitations. This by far better than letting the training program define my limitations by creating overuse injuries.

FWIW Joe Moya





Edited by Joe M 2005-06-13 8:51 AM

Curious about your back problem.  For me it's obviously the muscle mass on either side of my lower back that gets tigh and nothing around my spinal column that I would expect to feel if there were a disc problem.  And when I say "lower back" I'm talking about the area around the weaistline of my shorts just above my "crack".  Actually, if you check out this picture (BURN) and you see the two bands of muscle that form a "V" going to my a$$...that's where the tightness is centered and spreads out maybe 3-4 inches to either side.  Does this still sound familiar to you?

Maybe stretching more would help me.  I can't imaging I have a strength issue.  I do dedicated core work about 2x per week and deadlifts are a regular part of my lifting...although I haven't done back extensions or hypers in a couple months.  Maybe a little extra work in the gym...couldn't hurt I guess.

Radiated pain is common among back injuries... eventhough you don't consider this an injury... it actually is a type of injury. It is a repetive used injury that is chronic to a particular activity.

The type of specific injuries require specific diagnosis and specific therapy.

Exactly what that specific treatment is dependent upon the diagnosis. Typically, you can't simply get rid of it by stretching and strengthing in a generic fashion. Instead, you typically have to work with very specific stretching methods in addition to very specific strengthing excersices.

All to often, generalized stretching and/or strengthing excercises will not get rid of muscular imbalance or muscular/tendon/ligament scar tissue resistence. In fact, sometimes this aggrivates the issue by allowing the body to compensate with uninjured/stronger muscular contractions in a way that skeletal motion becomes limited to the area/movement of less pain. This commonly causes the injured area to remain in it's current condition.

The only solution is to find a proper diagnosis of what is now a minor problem. Unfortunately, the first step toward athletic improvement in performance while injured requires rest and recovery. Doing this usually accomplishes longer term positive results in performance.

Want to know my WAG? ... you might have a slightly herniated L-3,L-4,L-5 (take your pick) protruting away from the body. The treatment for such a condition is simple for now... but, as you age... that problem could become much worse and less likely cureable with simple treatment.

Bottom line, get it looked at... it could be nothing more than inflamation as a result of poor bike fit or poor running form. At any rate, you can tell just by looking... to get to the root of your problem, you need to start a process of elimanation. For best results, that process should begin while your still young and your body is capable of solving the problem without resorting to more serious treatments such as surgery.

FWIW Joe Moya

Try Yoga... and/or Pilates.

Also, try excersises using a Swiss Ball. If done right, they will kick your butt and make heavy weights look like a piece of cake.

Concentrating more on muscular balance and coordination typically will help the back much more than large muscle group strength excersises.

FWIW JOe Moya

When it comes to NSAID's and endurance sports it about... using a little common sense... None of the drugs were tested in the kind of conditions that some endurance athlete's use them in. As a result, the problems have not been fully researched.

When you know your going to put your kidney into a high stress mode... lighten up on the NSAID's BEFORE you do any high level of activity for extended periods of time.

And, don't think you can hydrate yourself into avoiding NSAID toxicity.... problems with NSAID toxicity induced Hyponatremea is that it doesn't work that way... it's about processing the fluids... not increasing the level of fluids in hopes that he body will absorb them into the body. If your kidneys not working properly, you can drink all the fluids in the world and will not help. In fact, it will complicate the situation.

FWIW Joe Moya

I'm getting the impression that there are possible health risks but if you use a little common sense it's nothing that should be a major concern.  Drinking too much water (and not replacing electrolytes) can lead to health problems too but that doesn't mean you shouldn't hydrate.  I appreciate the medical research references.  Thinking about it reasonably, if taking a couple Advil and exercising for 2-3 hours posed some serious health risk I would expect the FDA to be all over it.  I feel fairly confident that taking a couple Advil during a race won't cause me any significant issues.

Edited by TH3_FRB 2005-06-14 12:49 PM

...OK, so here is a post made on Slowtwitch in Feb. of 2003... she took an NSAID and almost suffered kidney failure... and, didn't even realize the cause of the problem when she made the original post... and, neither did it seem the doctors who treated her (not uncommon among doctors).

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overhydrated to death!!! Quote | Reply

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Hi there,

This is my first shot at this forum. I would love any info I could get on this topic.

June 27 I finished IM CDA, Idaho. I finished feeling very strong and I actually sprinted my last 1/2 mile. During the Marathon portion of the race (about mile18), I stopped taking in large amounts of water and was only able to sip on chicken broth to the end of the race. By that time in the race I also had taken about 5-6 Naproxen (anti inflam for my knees). Now here is where it gets interesting.

When I crossed the finish line I was asked what tent I would like to visit. I had requested an IV due to the fact that when I finish a race I get very bad stomach cramps due to dehydration (possibly). I was checked out and granted the request for an IV. I was very jolly through the even of being treated and I suddenly hit a wall. It wasn't until the 4th IV that I felt sick. I became nauseous, dizzy and the stomach pains were unbearable. After 2 hours in the tent, the medic asked me to stand up for a moment to check something out.....at that moment I blacked out.

I awoke 5 hours later in the ER with a total of 8 IV bags in me and a blood pressure record of 50/30 and 60/30. I was kept overnight and released the next day upon keeping some food down.

I weighed in at 137lbs for the race on Sunday, I checked out of the Hospital weighing 165lbs. I was not able to eat for 2 days due to the "lack of room" in my body. If I ate, I couldn't breath and if I wanted to breathe I would have to just stay hungry.

I have been told I was hyponatremic due to the amount of solution put into me ...I have also been told that by my blood pressure it could have been fatal. Can someone explain what happened and why did it get so bad. I thought I was simply dehydrated from the race.....this was the last thing I thought would have happened.

Any info would be great

Thank you \Vanessa

Complete thread at...

http://forum.slowtwitch.com/gforum.cgi?post=39401;search_string=tak...
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This is a classic example of what the results can be from taking NSAID's during or before a race...

This is also anecdotal evidence contrary to what BrianPBN seems to have experienced and you have noted as an "OK" use of NSAID's...

These are the facts:

1) NSAID's have a correlative relationship to the cause of Hyponatremia.
2) It is NOT predictable.
3) Probabilities of occurance have not been determined.... except for the fact that NO NSAID useage results in NO NSAID toxicity induce Hyponatremia.... While use of NSAID's can cause kidney problems without a significantly predictable high risk group.

Each individual has different abilities to tolerate drugs under different conditions/environments. There is no way to predict what is the correct dosage or usage/longevity of drug useage among certain individuals and still make a claim with a high degree of certainty claim that it would be "OK". There is no way anyone can say that a top rank triathlete who may be only 25 yrs. old may have a higher tolerance for toxicity than a 55 yr. Age Grouper.... there is simply no established benchmark that determines high risk groups. There is only a very strong indication that it does have the potential for producing permanent kidney damage.... and, if you look at how the drug works, it's not a big leap to see this correlation assumption is mark on.

If (say) the odds are only a 100,000 to 1 of having harmful side effects from NSAID's... does that justify it's use? Don't know... but, I don't think I'm willing to take the chance... specially if the issue can be most likely solved with correct training and proper diagnosis of the problem.

FWIW

Joe Moya

Edited by Joe M 2005-06-14 6:39 PM

"...if taking a couple Advil and exercising for 2-3 hours posed some serious health risk I would expect the FDA to be all over it. "

Sorry, but this expectation is unfortunately wrong...

I don't see that being a high priority by the FDA since this is such a minory population and narrow degree of useage. I remember a conversation some time ago where a few researchers had been trying for years to get grants to study this very issue and have been unsuccessful. It's just not high on the list of important issues to study... why? ...because it is not that common among the general population.

Unfortunately, there seems to be more about what we don't know than what we do know... which in and of itself makes this subject of using NSAID's during endurance events much less predictable.

My feeling toward NSAID's is balanced. NSAID's are not bad... but, they can be if used incorrectly. It is about using them correctly (as you mentioned)... and, the correct way is to apply them from a recovery point of view.

FWIW
Joe Moya

BTW. you might want to take a look at this interesting new information regarding NSAID's...

http://www.caringmedical.com/sports_injury/nsaids.asp



Edited by Joe M 2005-06-14 7:10 PM

5-6 Naproxin is a bit different than a couple of advil to kill some soreness pain.....

Well,... I agree... this is where the common sense aspect of using NSAID's comes into play.

Unfortunately, no one know the limits of what is the acceptable dosage (and/or prior usage) of NSAID's and an endurance event. I think there are too many variables to say with certainty what is "too much".

My WAG is simular to yours... 5-6 Naproxin is definately over board... not to mention what the dosage level and length of time on NSAID's may have been prior to the event. But, there are other situations where only small amounts of NSAID useage has had the same effect because of the conditions. Another one of my WAG is that conditions that are extreme heat and/or high humidity with long endurance distances could trigger a toxcity effect eventhough the dosage level may have been acceptably low and for only a short period of time.

I think NSAID useage and endurance sports gets back to my Russian Roulette sort of analogy. Only, we really don't know how many bullets are in the chamber... and, at times there is some level of uncertainty whether or not there is a gun present. There certainly is a lot of details that is not known about NSAID's and endurance sports. More specifically, I do think that with certain individuals there is a high potential of kidney related problems... while in others there are not. Unfortunately, no one knows this risk group much less the correlative effects fo environment and dosage. We only have some studies that indicate this correlation between NSAID's usage and Hyponatremia.

FWIW Joe Moya

It is not much spoken of, but it is very common for Ironman athletes to have a few ibuprofen tablets in their special needs run bag. Whether or not it is safe medically is not for me to determine, plenty written on the subject in the posts above. But it sure as crap makes those last 13 miles a whole lot more tolerable. It is almost as good a boost to the energy level and enjoyment aspect of the race at that point as it is to drink a coca cola in the last hour. I don't know of the same thing going on during the bike, and have never felt the same overall body ache that I do during the marathon portion.

I have had an ongoing battle with arthritis for most of my adult life. It is what has led to my knee replacements. I have tried to cut the Naproxen but the tenderness just keeps coming back. I'm not lookig to win any races. My goal is to train and complete a couple of sprints each summer. I love the bike, I love swimming and I love weight training. I am following my doctor's advice through and through. Am I inconflcit with the rules of the triathlon by taking naproxen on a daily basis?

Nope...not as far as I can tell.  It's a legal OTC med that you are taking for a legit reason.