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Use of NSAIDs in triathletes: Prevalence, level of awareness and reasons for use

Article  in  British Journal of Sports Medicine · September 2009

DOI: 10.1136/bjsm.2009.062166 · Source: PubMed

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Use of Nonsteroidal anti-inflammatory drugs

(NSAIDs) in triathletes: prevalence, level of
awareness, and reasons for use
Tatiane Gorski, Eduardo Lusa Cadore, Stephanie Santana Pinto, Eduardo
Marczwski da Silva, Cleiton Silva Correa, Fernando Gabe Beltrami and Luiz
Fernando Martins Kruel

Br. J. Sports Med. published online 6 Aug 2009;

doi:10.1136/bjsm.2009.062166

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BJSM Online First, published on August 6, 2009 as 10.1136/bjsm.2009.062166

Original Article

Title: Use of nonsteroidal anti-inflammatory drugs (NSAIDs) in triathletes: prevalence,

level of awareness, and reasons for use

Corresponding Author: Tatiane Gorski¹

¹Federal University of Rio Grande do Sul, RS, Brazil
Adress for correspondence: Exercice Research Laboratory – Physical Education
School – UFRGS
750 Felizardo Furtado Street – Jardim Botânico – CEP 90690-200
Porto Alegre – RS – Brazil
FAX: + 55 51 33085842
Phone: + 55 51 84626920
E-mail: tatigorski@gmail.com

Other authors: Eduardo Lusa Cadore¹, Stephanie Santana Pinto¹, Eduardo

Marczwsky da Silva¹, Cleiton Silva Correa¹, Fernando Gabe Beltrami², Luiz Fernando
Martins Kruel¹
² University of Cape Town, Department of Human Biology, Sports Science Institute of
S.A., Cape Town, South Africa

Keywords: nonsteroidal anti-inflammatory drugs, Ironman, triathlon

Word Count: 1845

Copyright Article author (or their employer) 2009. Produced by BMJ Publishing Group Ltd under licence.
 Downloaded from bjsm.bmj.com on 18 August 2009

ABSTRACT

Objective: To determine the level of awareness regarding nonsteroidal anti-

inflammatory drugs (NSAIDs), and the prevalence and reasons for their consumption
among athletes competing at the 2008 Brazil Ironman Triathlon (3,8-km swim, 180-km
cycle, and 42,2-km run).
Design: Survey study.
Setting: 2008 Brazil Ironman Triathlon, Florianópolis, Brazil, May 2008.
Participants: Three hundred and twenty-seven of the 1250 athletes competing at the
2008 Brazil Ironman Triathlon were enrolled in the study.
Main Outcome Measures: Athletes answered a questionnaire about NSAID effects,
side-effects and consumption at the bike check out or awards lunch.
Results: One hundred ninety-six (59.9%) athletes reported using NSAIDs in the
previous three months; of these, 25.5% (n=50), 17.9% (n=35) and 47.4% (n=93)
consumed NSAIDs the day before, immediately before and during the race,
respectively. Among NSAID users, 48.5% (n=95) consumed them without medical
prescription. The main reason given for NSAID consumption in the previous three
months was the treatment of injuries, while the main reason given for consuming
NSAIDs during the race was pain prevention. Despite anti-inflammatory and analgesic
effects, most athletes were unaware of the effects of NSAIDs, and the only adverse
effects known by most athletes were the gastrointestinal complications.
Conclusions: This study found a high prevalence of NSAID consumption, limited
awareness of the effects and side-effects of them and a high rate of non-prescribed
use. It is suggested that long distance triathlon events include in their programmes
educational devices – like talks or folders – about NSAID use, effects and side-effects.

ABSTRACT Word Count: 243

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INTRODUCTION
Nonsteroidal anti-inflammatory drugs (NSAIDs) have anti-inflammatory,
analgesic and antithermic actions.[1-3] Moreover, aspirin has an antithrombotic
effect,[4,5] while inhibitors of cyclooxygenase-2 (coxibs) can create proaggregatory
conditions, contributing to their side-effects.[6] The use of NSAIDs by athletes from
different sports modalities has been widely reported by many authors[7-19] and they
represent one of the classes of medicines most used by athletes.[20]
With their widespread use in sport medicine, either as a prescription or over-
the-counter drug,[21] NSAIDs such as aspirin and ibuprofen are cited by Martin and
Coe,[22] in their publication for running coaches, as one of the means to of optimizing
recuperation after training sessions.
Often, athletes with minor injuries do not stop training and competing in order to
treat them, but instead take NSAIDs, frequently in inappropriate doses and for
prolonged periods.[8-14] On the other hand, Warner et al.,[7] when researching the use
of NSAIDs by football players with an average age of 15.8 years, found that of the 452
athletes that reported using NSAIDs in the 3 months prior to the survey, 108 took such
medicine to prevent feeling pain and 245 noted improved performance.
In triathlon, Wharam et al.[12] found that 100 of the 333 athletes enrolled in their
study at the 2004 New Zealand Ironman had consumed NSAIDs during the race.
However, the reasons triathletes take NSAIDs and their awareness regarding the
effects and side-effects of such medications remain unclear. Therefore, the present
study aims to determine the prevalence, reasons for use and level of awareness of
NSAIDs among triathletes participating in the 2008 Brazil Ironman.

METHODS
Athletes were invited to participate in the study at the bike check-out and
awards ceremony, after the race; much athletes as possible were invited. Written
informed consent was obtained from 327 (300 male and 27 female) athletes – 26,26%
of the 1250 athletes competing in the race. Ethical approval for the study was obtained
from the Federal University of Rio Grande do Sul Ethics Committee; 2008 Brazil
Ironman Scientific Commission approved the study too.
The triathletes enrolled in the study (300 male and 27 female) were procedding
from 23 different countries, 36,93±8,02 years old, had practiced triathlon for 6,99±5,70
years and completed 3,38±4,32 Ironman races; 18 (5,5%) were professional and 309
(94,5%) were amateur. Figure 1 shows athletes distribution according to their finish
times (men’s winner =8h28min24s and women’s winner = 9h56min08s), and Figure 2
shows athletes distribution by continent of origin.
(INSERT FIGURE 1)
(INSERT FIGURE 2)
Athletes answered a questionnaire about NSAID awareness and consumption,
based on previous studies.[7,23,24]
The questionnaire contained questions about personal data for sample
characterization; medical complications during and after the race (where athletes
described their medical complications during and after the race; after, the medical
complications reported by athletes were divided into categories); the effects and the
side-effects of NSAIDs, where athletes marked the effects and side-effects they were
aware of (Figure 3); and questions about NSAID consumption in the previous 3
months, on the day before the race, and on the race day (before and during), which
included NSAIDs type and dose, reasons for consumption and professional that
prescribed the drug.
(INSERT FIGURE 3)
Data were analyzed using descriptive statistics, made with SPSS 13.0 software.

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RESULTS
Of the 327 interviewed athletes, 59.9% (n=196) reported consuming NSAIDs in
the previous 3 months. Of these, 196 users 25.5% (n=50) consumed NSAIDs on the
day before the race, 17.89% (n=35) consumed NSAIDs immediately before the race,
and 47.4% (n=93) consumed NSAIDs during the race. Among athletes who used
NSAIDs in the three months before the race, 19.38% (n=38) had consumed NSAID on
more than one occasion (i.e., before and during the race; or on the day before and
during the race; or on the day before and immediately before the race; or in the three
situations). Data on the level of awareness regarding the effects and side-effects of
NSAIDs are shown in Table 1. The side-effects cited in the field “other” were cramps,
allergy, somnolence, headache, decrease in performance and tachycardia.

Table 1: Number (%) of athletes aware of the effects associated with the consumption of
nonsteroidal anti-inflammatory drugs (NSAIDs).
Athletes who known the effect / side-effect
Expected effects Total sample Users Non-users
(n=327) (n=196) (n=131)
Anti-inflammatory 258 (78,9%) 156 (79,6%) 102 (77,9%)
Antithrombotic 32 (9,8%) 19 (9,7%) 13 (9,9%)
Antithermic 68 (20,8%) 46 (23,5%) 22 (16,8%)
Analgesic 209 (63,9%) 148 (75,5%) 61 (46,6%)
Other 2 (0,6%) 2 (1,0%) 0 (0,0%)
Side-effects
Gastrointestinal complications 192 (58,7%) 125 (63,8%) 67 (51,1%)
Renal complications 89 (27,2%) 61 (31,1%) 28 (21,4%)
Kidney failure 60 (18,3%) 41 (20,9%) 19 (14,5%)
Stomach bleeding 78 (23,9%) 51 (26,0%) 27 (20,6%)
Other 19 (5,8%) 14 (7,1%) 5 (3,8%)

Of the athletes who had used NSAIDs in the previous 3 months, 7.7% (n=15)
reported daily use, 8.7% (n=17) reported weekly use, and 83.7% (n=164) reported
rarely use.
Reasons for NSAIDs consumption cited by athletes are in Table 2. Professional
prescribing NSAIDs are in Figure 4.

Table 2: Reasons for nonsteroidal anti-inflammatory drugs (NSAIDs) consumption among users
(n=196).
Consumption Consumption Consumption Consumption
in the previous one day before immediately during the
3 months the race before the race race
(n = 196) (n = 50) (n = 35) (n = 93)
Injury treatment 65 (33,2%) 8 (16,0%) 7 (20,0%) 11 (11,8%)
Pain prevention at training 45 (22,9%) - - -
Pain prevention at race 47 (24,0%) 26 (52,0%) 20 (57,1%) 58 (62,4%)
Pain relief at training 52 (26,3%) 15 (30,0%) - -
Pain relief at Racing 45 (22,9%) - 8 (22,8%) 43 (46,2%)
Other 32 (16,3%) 12(24,0%) 6 (17,1%) 2 (2,1%)

(INSERT FIGURE 4)

Medical complications were divided into 12 groups: Dehydration, Hyponatremia,

Gastrointestinal Problems, Cramps, Tendinopathies, Asthma, Hypothermia,
Hypotension, Headache, Bone Fractures and Orthopedic Problems, Hyperventilation
and Muscular Spasms. Data on the frequency with which these events occurred, as
well as the use or otherwise of NSAIDs during and after the race are found in Tables 3
and 4.

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Table 3: Medical complication during the race (NSAIDs: nonsteroidal anti-inflammatory drugs)
Medical complication during the race NSAIDs consumption during the race
Yes (n=93) No (n=234)
Dehydration 1,1% (n=1) 0,4% (n=1)
Hyponatremia 2,2% (n=2) 0% (n=0)
Gastrointestinal problems 7,5% (n=7) 5,1% (n=12)
Cramps 5,4% (n=5) 2,1% (n=5)
Tendinopathies 0% (n=0) 0,9% (n=2)
Asthma 0% (n=0) 0,4% (n=1)
Hypothermia 0% (n=0) 0,4% (n=1)
Hypotension 0% (n=0) 0,4% (n=1)
Headache 0% (n=0) 0,4% (n=1)
Hyperventilation 0% (n=0) 0% (n=0)
Bone fractures and orthopedic problems 2,2% (n=2) 2,1% (n=5)
Muscular spasms 0% (n=0) 0% (n=0)
None 84,9% (n=79) 88,5% (n=207)

Table 4: Medical complication after the race (NSAIDs: nonsteroidal anti-inflammatory drugs)
Medical complication after the race NSAIDs consumption during the race
Yes (n=93) No (n=234)
Dehydration 1,0% (n=1) 0,4% (n=1)
Hyponatremia 0% (n=0) 0% (n=0)
Gastrointestinal problems 3,2% (n=3) 0,9% (n=2)
Cramps 2,2% (n=2) 0,4% (n=1)
Tendinopathies 0% (n=0) 0,4% (n=1)
Asthma 0% (n=0) 0% (n=0)
Hypothermia 0% (n=0) 0,9% (n=2)
Hypotension 0% (n=0) 0% (n=0)
Headache 0% (n=0) 0% (n=0)
Hyperventilation 0% (n=0) 0,4% (n=1)
Bone fractures and orthopedic problems 1,0% (n=1) 1,3% (n=3)
Muscular spasms 0% (n=0) 0,4% (n=1)
None 92,5% (n=86) 95,3% (n=223)

DISCUSSION
The main results found in this study were the high prevalence of consumption of
NSAIDs and the limited awareness of the athletes regarding the effects and side-
effects of the medicines.
The high prevalence of the use NSAIDs found in the present sample (59.9%)
corroborates similar findings in previous studies listed in Table 5. However, it
represents practically double the percentage found by Wharam et al.[12] - 30%-, who
analyzed a similar number of athletes (333) participating in a similar race (New Zealand
Ironman). This difference may be due to the analysed period (24hs before the race x
three previous months).

Table 5: Prevalence of nonsteroidal anti-inflammatory drugs (NSAIDs) consumption in several

sports.
Study Sport Modality / Data source / Situation n Prevalence
Warner et al.[7] Football / Athletes (self-administered 604 75%
questionnaire) / three previous months (training
and competition)
Corrigan and Several (Sydney Olympic Games) / athletes 2758 25,6%
Kazlauskas[8] (doping control form) / previous three days
(competition)

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Reid et al.[9] Marathon / athletes / previous 24hs 134 13,4%

(competition)
Nieman et al.[10] Ultramarathon (160-km) / athletes / during the 60 71,6%
race
Huang, Johnson Several (canadian athletes competing at Atlanta 257 42%
and Pipe[11] Olympic Games) / athletes (personal interviews)
/ period not informed
Several (canadian athletes competing at 300 41%
Sydney Olympic Games) / period not informed
Wharam et al.[12] Triathlon – Ironman / athletes / 24hs before the 333 30%
race
De Rose et al.[13] Several (athletes selected for doping controla at 234 24,8%
South-American Games) / athletes
(questionnaire conducted in the doping control) /
three days before the competition
Alaranta et al.[14] Several (athletes finnancialy supported by 446 49,1%
Finnish National Olympic Commitee) / athletes
(structured questionnaire) / previous seven days
(training) / *only prescribed medication
Page et al.[15] Ultraendurance mountain run (60km) / athletes / 123 35%
24hs before and during the race
Taioli [16] Professional soccer players from the two Italian 743 92,6%
major leagues / team doctors / previous year
Tscholl, Junge Soccer players participating at FIFA World Cups 2944 Between
and Dvorak [17] 2002 and 2006 / team physicians / 72hs before 32,6% and
each match 54,8%
Van Thuyne and Several (doping control between 2002 and 2005 3858 12,03% (2002)
Delbeke[18] in Belgium and The Netherland, International 4417 12,63% (2003)
Cycling Union and Belgian Cycling Federation) / 5190 13,20% (2004)
athletes (doping control forms) / 3 days before 5180 12,76% (2005)
competition
Tscholl et al. [19] Female and youth male soccer players 2488 Between
participating in 6 international soccer 17,3% and
tournaments / team physicians / 72hs before 30,7%
each match

Of the athletes analyzed in the study by Alaranta et al.[14], 2% used NSAIDs

daily, and 4.9% used NSAIDs weekly, whereas, in the present study, these
percentages were 7.7% and 8.7%, respectively. This variation may be due to the
different sports modalities analyzed (various sports x triathlon), and the different level
of the athletes (professional x amateur and professional) where the demand for the use
of NSAIDs is different. Moreover, the values found by Alaranta et al. [14] refer to
physician-prescribed NSAIDs, while the values on the present study include non-
medically prescribed NSAIDs used too.
In a study by Huang, Johnson and Pipe[11] the chronic tendinopathies and
inflammation typical of sports that involve the shoulders, elbows and knees (among
them swimming and cycling) were indicated as partial justifications for the high
prevalence of NSAID consumption by athletes in these sports. Other authors suggest
as possible reasons for the high prevalence of NSAID consumption among athletes the
fact that athletes with minor injuries do not stop training and competing in order to cure
them, and instead take NSAIDs during training and competition, often at inappropriate
doses for prolonged periods.[8,14] In the present study, injury treatment represented
the main reason for the use NSAIDs in the 3 months prior to the race, corroborating the
explanations offered by the abovementioned authors.

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However, the main reason given for the use of NSAIDs on race day and the day
before was pain prevention, which tends to support the speculations made by Page et
al.,[15] that athletes running a mountain ultramarathon used NSAIDs to prevent
delayed-onset muscle soreness. Warner et al.[7] in their study of football players, found
23.9% used NSAIDs to block pain before it occurs (without specifying whether it was
during training or competition).This figure is similar to that for pain prevention in training
and during the race (3 months before the race) found in the present study, which were
22.9% and 24,0%, respectively. Additionally, Tscholl et al. [19] found that in soccer
players NSAIDs consumption was higher than injuries prevalence indicating a possible
use by athletes not fully recovered from injuries or receiving “prophylactic pain-
treatment”.
It can be seen from the present results that, with the exception of the anti-
inflammatory and analgesic effects, the effects provoked by the consumption of
NSAIDs were not known by more than half the sample that answered the
questionnaires. The same was true in relation to the side-effects, of which only the
gastrointestinal problems were recognized as possible side-effects by more than half
the sample. As NSAID consumption was reported by 59.9% of the interviewees, this
indicates a high prevalence of consumption of such medicines together with a low level
of awareness regarding the effects of such drugs, which represents a serious cause for
concern. This is similar to the findings in the study by Warner et al.[7], where the
prevalence of NSAID consumption among football players was associated with a low
perception of disadvantage in NSAID consumption.
A number of studies have reported an association between NSAID consumption
and alterations in kidney function [9,25,26] and the occurrence of hyponatremia[12, 27]
in long distance sports events. In the present study, hyponatremia was reported as a
medical complication during the race by 2 athletes, both of whom had used NSAIDs
during the race. It is important for athletes to be aware of the possible increased risk of
kidney alterations and hyponatremia with the use of NSAIDs. In the present study,
none of the athletes mentioned hyponatremia as a side-effect of using NSAIDs, and
only 27% of the athletes identified kidney problems among the possible side-effects of
NSAIDs.
Gastrointestinal problems are common in endurance athletes and the effects of
exercise on gastrointestinal tract are well established, but the role played by NSAIDs in
such problems is not yet clear.[28] In the present study, the percentage of athletes that
declared having gastrointestinal problems during and after the race was slightly higher
among the NSAID users. In the study of Alaranta et al. [14] gastrointestinal-related
adverse effects were also the main adverse effects reported by athletes using NSAIDs;
the percentage found by them (8.6%) is also similar to that found during the race in our
study.
It should be pointed out that in the present study the data concerning the
incidence of medical complications, like hyponatremia and gastrointestinal problems, is
based only on the reports given by the athletes, and is not the result of clinical or
biological tests. Therefore, it is not possible to speculate relations of cause and effect
of the use of NSAIDs and the incidence of hyponatremia, gastrointestinal problems or
other complications, although the data can be said to suggest a tendency.
The high percentage of NSAID consumption without medical prescription found
by Warner et al.[7], 51.3%, is similar to that found in the present study. This practice is
contrary to the recommendation made by Van Thuyne and Delbeke[18] who suggests
that, even though the use of NSAIDs and other drug categories is permitted by the
World Antidoping Agency, athletes and their physicians should not administer them
without medical necessity. Moreover, the prescription of NSAIDs by coaches, dietists,
physiotherapists and pharmacists highlights that this activity is made by professionals
who are not always the most apt to prescribe medication.

CONCLUSION

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The data in the present study show a high prevalence of the consumption of
NSAIDs among the triathletes participating in the 2008 Brazil Ironman included in the
sample, together with a low awareness of the effects and side-effects of NSAIDs. The
main reason for NSAID consumption in the 3 months prior to the race was injury
treatment, but pain prevention represented the main motive for taking such drugs
during the race. The results of the present study suggest the need for the inclusion of
educational devices, such as talks and folders on the use of NSAIDs, in the planning of
long distance triathlon races, in order to make athletes aware of the risks and benefits
that these drugs offer.

ACKNOWLEDGMENTS
We thank the financial support of Federal University of Rio Grande do Sul and
National Council for Scientific and Technological Development (CNPq), Brazil Ironman
Scientific Commission, and the participation of the athletes.

COMPETING INTERESTS
None.

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FIGURE LEGENDS
Fig. 1: Distribution of athletes by finish time.
Fig. 2: Distribution of athletes by continent of origin.
Fig. 3: Questions about effects and the side-effects.
Fig. 4: Professional prescribing NSAIDs.

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