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 327 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 checkout or awards lunch.
Results 196 (59.9%) Athletes reported using NSAIDs in the previous 3 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 3 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 nonprescribed use. It is suggested that long-distance triathlon events include in their programmes educational devices such as talks or folders about NSAID use, effects and side effects.
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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 can create pro-aggregatory 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, as either a prescription or an 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 of optimising recuperation after training sessions.
Often, athletes with minor injuries do not stop training and competing 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 who reported using NSAIDs in the 3 months before the survey, 108 took such medicine to prevent feeling pain and 245 noted improved performance.
In triathlon, Wharam et al12 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 Triathlon.
Athletes were invited to participate in the study at the bike checkout and awards ceremony after the race; as many athletes as possible were invited. Written informed consent was obtained from 327 (300 males and 27 females) 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; the 2008 Brazil Ironman Scientific Commission approved the study, too.
The triathletes enrolled in the study (300 males and 27 females) were from 23 different countries, were 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=8 h 28 min 24 s and women's winner=9 h 56 min 08 s), and fig 2 shows the athletes distribution by continent of origin. Athletes answered a questionnaire
The questionnaire contained questions about personal data for sample characterisation; medical complications during and after the race (where athletes described their medical complications during and after the race, then the medical complications reported by the 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 (fig 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 the professional who prescribed the drug.
Data were analysed using descriptive statistics made with the SPSS V.13.0 software.
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), immediately before the race; and 47.4% (n=93), during the race. Among the athletes who used NSAIDs in the 3 months before the race, 19.38% (n=38) had consumed NSAIDs on more than one occasion (ie, before and during the race, 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.
Of the athletes who had used NSAIDs in the previous 3 months, 7.7% (n=15) reported daily use; 8.7% (n=17), weekly use; and 83.7% (n=164), rare use.
Medical complications were divided into 12 groups: dehydration, hyponatremia, gastrointestinal problems, cramps, tendinopathies, asthma, hypothermia, hypotension, headache, bone fractures and orthopaedic problems, hyperventilation, and muscular spasms. Data on the frequency with which these events occurred and the use or otherwise of NSAIDs during and after the race are found in tables 3 and 4.
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 of 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 al12 (30%) who analysed a similar number of athletes (333) participating in a similar race (New Zealand Ironman). This difference may be due to the analysed period (24 h before the race × 3 previous months).
Of the athletes analysed 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 analysed (various sports × triathlon) and the different levels of the athletes (professional × amateur and professional), where the demand for the use of NSAIDs is different. Moreover, the values found by Alaranta et al14 refer to physician-prescribed NSAIDs, while the values on the present study also include non-medically prescribed NSAIDs used.
In a study by Huang et al,11 the chronic tendinopathies and inflammation typical of sports that involve the shoulders, elbows and knees (among them are swimming and cycling) were indicated as partial justifications for the high prevalence of NSAID consumption by athletes in these sports. Other authors suggest as a possible reason for the high prevalence of NSAID consumption among athletes the fact that athletes with minor injuries do not stop training and competing 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 of NSAIDs in the 3 months before the race, corroborating the explanations offered by the above-mentioned authors.
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 al15 that athletes running a mountain ultramarathon used NSAIDs to prevent delayed-onset muscle soreness. Warner et al7 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 al19 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 who 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 function9 25 26 and the occurrence of hyponatremia12 27 in long-distance sports events. In the present study, hyponatremia was reported as a medical complication during the race by two 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 who declared having gastrointestinal problems during and after the race was slightly higher among the NSAID users. In the study by Alaranta et al,14 gastrointestinal-related adverse effects were also the main adverse effects reported by athletes using NSAIDs; the percentage they found (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, such as hyponatremia and gastrointestinal problems, are based only on the reports given by the athlete, and are 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 (51.3%) of NSAID consumption without medical prescription found by Warner et al7 is similar to that found in the present study. This practice is contrary to the recommendation made by Thuyne and Delbeke18 who suggest 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.
The data in the present study show a high prevalence of the consumption of NSAIDs among the triathletes participating in the 2008 Brazil Ironman Triathlon 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 before 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 to make athletes aware of the risks and the benefits that these drugs offer.
The authors thank the Federal University of Rio Grande do Sul and the National Council for Scientific and Technological Development for the financial support, the Brazil Ironman Scientific Commission, and the athletes for their participation.
Competing interests None.
Ethics approval This study was conducted with the approval of the Federal University of Rio Grande do Sul Ethics Committee (number 2007866).
Provenance and peer review Not commissioned; externally peer reviewed.