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Pictured: West Ham United’s Michail Antonio lays on the ground after he picks up an injury during the Premier League match at Bournemouth in March 2017.
NON-STEROIDAL ANTI-INFLAMMATORY DRUGS FEATURE/DR. CRAIG ROSENBLOOM - LEYTON ORIENT FC Excessive anti-inflammatory drug use in elite sports has been well documented with football having some of the highest rates of use of any sport (1)
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on-steroidal anti-inflammatory drugs (NSAIDs) are commonly used painkillers used to treat soft tissue injuries due to their anti-inflammatory and analgesic effects. Commonly used drugs in this group include but are not limited to ibuprofen, naproxen, and diclofenac. The largest data source relating to football currently available is from the FIFA World Cups. Since the 2002 World Cup any medication that has been administered by a team physician to a player 72 hours prior to a game has been recorded (2). At the last World Cup in Brazil, just over half of the 736 players present at the competition took an NSAID during the tournament. Nearly a third of all players used an NSAID prior to every match regardless of whether they played, which is roughly 7 out of the 23 players per national squad per match (3). Much higher rates of medicine use were seen in older players, and also players from the South American and Asian Confederations (3). There was no difference in
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rates of use in injured vs. non injured players, or between players participating in the match and substitutes who did not play at all (4). Looking across the game as a whole - similar rates of NSAID use were found at the 2003 and 2007 FIFA Women’s World Cup (4). In a younger population players at the 2005 and 2007 Under-17 and Under-20 World Cup tournaments, 43% of participants used an NSAID during the competition (4). Unfortunately no recent data has been published. At the FIFA Futsal World Cup between 2000 and 2012, 45.7% of players took at least one NSAID during the competition, with a quarter taking at least one NSAID prior to every game (5). Efforts have been made to try and reduce rates of NSAID use, and before the 2010 FIFA World Cup the FIFA Medical Assessment and Research Centre (F-MARC) campaigned to reduce the use of NSAIDs during the tournament. Team physicians were informed about the potential side effects, and the detrimental effects on recovery after exercise
and tissue healing (4). Despite this; rates of NSAID use per match at the 2010 World Cup increased 5% compared to 2006 (6). At the 2014 World Cup NSAIDs were the most commonly taken physician provided medication at the tournament, accounting for over 40% of all medicines taken. Diclofenac was by far the most popular NSAID accounting for 60% of use, with selective COX-2 inhibitors accounting for 16.4% (3). The medical team are an important influence given the prescription only nature of most NSAIDs. In the 2002 FIFA World Cup one country used more than one type of NSAID per player per match throughout the entire tournament (4). During a FIFA Futsal World Cup the players from two entire teams were all prescribed the same NSAID by their team physician before every game (5). Physician prescribed figures might underestimate NSAID use as this does not include any self administered medication by the players themselves (4). Data from domestic leagues is scare. In
football medic & scientist Scottish professional football between 2008 and 2012, NSAIDs were the most commonly declared medication on doping control forms accounting for 30%. Players over the age of 26 had a higher rate of use than younger players (7). A study of the top two tiers of Italian professional football found that 93% of players used an NSAID in the previous year, with 86% currently using one, and 22% using one for more than 60 days per a year (8). Why does it matter? NSAIDs work by inhibiting prostaglandin synthesis in the COX pathway. Despite their frequent use, NSAIDs are not suitable for the treatment of all soft tissue injuries as inflammation can play an important role in tissue repair. Animal and human studies have shown that inhibiting prostaglandin synthesis can delay tendon healing, and can increase non-union rates in fractures (9, 10). If NSAIDs are used during the destructive phase of muscle damage the remodelling phase can be limited which can increasing recovery times (9). It is well recognised that even short term NSAID use can have serious health risks (11). These include kidney, gastro-intestinal, and cardiovascular complications. Increasingly strong links between NSAID use and low sodium blood levels (hyponatraemia) are being described (12). Gastro-intestinal side effects include ulceration, erosion, perforation, and bleeding of the stomach. Symptoms can include abdominal pain/cramps, nausea, and indigestion. 30-70% of athletes using NSAIDs report one of these side effects (13). During exercise blood flow through the kidneys can increase by 50%, however NSAIDs reduce kidney blood supply. Reducing kidney blood supply during a time of increased kidney demand can result in permanent kidney damage. An American study associated up to 10% of all kidney failure to NSAID use (9). The increased cardiovascular risks that NSAID use has been shown to have is very concerning, especially that of diclofenac which was the most commonly prescribed NSAID at the World Cups (14). What can I do? If an oral NSAID is indicated then evidence would recommend using the smallest dose, for the shortest time, with attention being made when selecting which one to use. Alternatives to oral NSAIDs include topical preparations (patches and gels) which only accounted for 7% of NSAID use at female and youth World Cups (15). Studies have shown that these might be suitable alternatives for use in acute soft tissue injuries and have low adverse event rates (16). Alternative oral analgesics are an underused option, with paracetamol only accounting for 5% of all medication used at World Cups (4). Further research is needed to look at rates of use in the professional domestic game, including what is the perceived benefit of taking it. Has taking NSAIDs simply become a normal behaviour for players and the medical staff?
Pictured: Tottenham Hotspur’s Kieran Trippier clashes with Wycombe Wanderers’ Myles Weston, leading to Tripper suffering an injury .
REFERENCES 1. Thuyne WV, Delbeke FT. Declared use of medication in sports. Clinical journal of sport medicine : official journal of the Canadian Academy of Sport Medicine. 2008;18(2):143-7. 2. FIFA Anti-doping [Available from: http://www.fifa.com/mm/document/tournament/ competition/01/47/38/17/regulationsfwcbrazil2014_update_e_neutral.pdf. 3. Vaso M, Weber A, Tscholl PM, Junge A, Dvorak J. Use and abuse of medication during 2014 FIFA World Cup Brazil: a retrospective survey. BMJ Open. 2015;5(9). 4. Tscholl PM, Vaso M, Weber A, Dvorak J. 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. British journal of sports medicine. 2015;49(9):580-2. 5. Pedrinelli A, Ejnisman L, Fagotti L, Dvorak J, Tscholl PM. Medications and Nutritional Supplements in Athletes during the 2000, 2004, 2008, and 2012 FIFA Futsal World Cups. Biomed Res Int. 2015;2015:870308. 6. Tscholl PM, Dvorak J. Abuse of medication during international football competition in 2010 - lesson not learned. British journal of sports medicine. 2012;46(16):1140-1. 7. Mercer A, Hillis W. Medication and supplement use in Scottish professional football. Scottish Medical Journal. 2014;59(3):E30-E. 8. Taioli E. Use of permitted drugs in Italian professional soccer players. Br J Sports Med. 2007;41(7):439-41. 9. Lippi G, Franchini M, Guidi GC. Non-steroidal anti-inflammatory drugs in athletes. British journal of sports medicine. 2006;40(8):661-3. 10. Mehallo CJ, Drezner JA, Bytomski JR. Practical management: nonsteroidal antiinflammatory drug (NSAID) use in athletic injuries. Clinical journal of sport medicine : official journal of the Canadian Academy of Sport Medicine. 2006;16(2):170-4. 11. Day RO, Graham GG. Republished research: Non-steroidal anti-inflammatory drugs (NSAIDs). British journal of sports medicine. 2013;47(17):1127. 12. Wharam PC, Speedy DB, Noakes TD, Thompson JMD, Reid SA, Holtzhausen L-M. NSAID Use Increases the Risk of Developing Hyponatremia during an Ironman Triathlon. Medicine & Science in Sports & Exercise. 2006;38(4):618-22. 13. Waterman JJ, Kapur R. Upper gastrointestinal issues in athletes. Current sports medicine reports. 2012;11(2):99-104. 14. Pawlosky N. Cardiovascular risk: Are all NSAIDs alike? Canadian Pharmacists Journal : CPJ. 2013;146(2):80-3. 15. Tscholl P, Feddermann N, Junge A, Dvorak J. The use and abuse of painkillers in international soccer: data from 6 FIFA tournaments for female and youth players. The American journal of sports medicine. 2009;37(2):260-5. 16. Kuehl KS. Review of the efficacy and tolerability of the diclofenac epolamine topical patch 1.3% in patients with acute pain due to soft tissue injuries. Clin Ther. 2010;32(6):1001-14.
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