NSAIDs. What are they and should athletes be using them? Are there risks, should you swear them off? These might be questions that you have never asked yourself.  Many athletes trust them to be safe and even find them helpful. Hopefully, after reading this post you have more information to make the best decision for you.

NSAIDs or nonsteroidal anti-inflammatory drugs are a class of drugs used to relieve pain and reduce inflammation.  They can be obtained over-the-counter (OTC) or prescribed, and most commonly seen OTC as aspirin, ibuprofen (Advil, Motrin), and naproxen (Aleve, Naprosyn). 

There are a few things that make this topic interesting to me:

• I had an experience in high school that lead to my own avoidance of NSAIDs.
• I’ve worked with athletes who have experienced acute kidney injury (AKI) from their NSAID use.
• I often see athletes take them or talk about taking them as a preventative measure or to help recovery faster. 

My personal story

I grew up swimming on my local competitive team which naturally transitioned me to the high school team. Like many swimmers, I experienced some shoulder soreness at the height of the season my junior year, so I began taking Aleve (naproxen) prior to practice. One Saturday during sprints at the end of a long practice, I started to feel nauseous but decided to push through since we only had a few more to go.  As I was reaching for the wall on my very next sprint, I saw my arm and hand blotchy with hives. I told/showed a coach, ran to the locker room, and got dressed as quickly as possible while noticing hives everywhere and taking some extra time to scratch the ones on my scalp with my comb (relief!). The next segment of time is a little blurry but I think a friend drove me to my mom who was nearby at the junior high watching my brother’s basketball game.  I made it to the doctor’s office amidst some vomiting where I received a shot of epinephrine to make it all go away.  The doc recommended avoiding NSAIDs completely citing that I may have an allergy.  That experience was enough for me to steer clear of them. 

In retrospect, I don’t think I have a true allergy. I was taking them the week prior with no reaction, but under certain conditions maybe it was too much for my body. Habitual use (only a week, I think) and high intensity exercise are the conditions I’m certain of. I can speculate that I was most likely dehydrated as well, I was in high school after all.

Athletes in the wild

Whatever the reason for my response, I have avoided them since, but my experiences as a practitioner make me wonder what my relationship with them would be if that didn’t happen.  And it makes me curious about other athlete’s use of them.  My conversations with athletes reveal a level of trust in an approved drug on the market.  If it helps them get through a workout or feel better sooner, who doesn’t want that — my high school self can relate. 

But the stories I’ve heard from athletes, young athletes, with no prior kidney dysfunction who have had blood in their urine and subsequent acute kidney injury make this a very important discussion.   

PSA – blood in your urine (or stool) is always a red-flag and not to be ignored. See your doctor immediately!  

So, what are the dangers of NSAIDs for athletes? 

The most studied outcomes of athletes ingesting NSAIDs are AKI, exercise-associated hyponatremia (EAH), gastrointestinal (GI) disturbances, and muscle damage; all concerning in their own right.

During exercise, more blood flow is needed in the muscles for movement and to the skin for cooling. Blood is diverted from other organs, including the kidneys, to sustain this arterial blood pressure. The reduction of blood flow in the kidneys reduces other important aspects of kidney function including glomerular filtration rate (GFR) (the amount of waste being filtered from the blood), sodium excretion, and urine flow. This is a normal response to exercise as a result of a concert of hormones directed by the sympathetic nervous system. The action of NSAIDs can further reduce blood flow to the kidneys creating an environment for kidney damage. AKI can last for a few days or weeks and it’s not clear what the long term impacts might be. It is apparent that dehydration increases the risk for AKI associated with NSAIDs.

Another consequence of the action of NSAIDs is increased water retention which can be a contributing element in over-hydration or hyponatremia (clinically low blood sodium concentrations). EAH is a very dangerous condition most notably related to endurance athletes and inadequate sodium concentrations in fluid or over consumption of water.

GI disturbances have been correlated to NSAID use when combined with prolonged exercise and heat. Gut injury and increased permeability are two areas of concern. For many endurance athletes who struggle with GI issues, it may be useful to consider if NSAIDs are exacerbating your issues.

Muscle damage or oxidative stress is another area gaining attention in research. NSAIDs are theoretically supposed to reduce inflammation but when combined with exercise they may actually increase it. 

Weighing the risks

For all of these potential outcomes the research has limitations: small sample sizes, very few randomized controlled trials, and varied methodologies that make it hard to compare results, so more work if definitely needed. Despite this, one thing is clear regarding NSAIDs and exercise;  if you add on dehydration, heat, and long durations the likelihood of an adverse outcome increases.  Combined with little evidence to support the idea that NSAIDs contribute to performance gains, the risk – reward calculation seems fairly straight forward.  What do you think?

Share your story

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References

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7. McDermott B, Smith C, Butts C, et al. Renal stress and kidney injury biomarkers in response to endurance cycling in the heat with and without ibuprofen. J Sci Med Sport. 2018;21(12). doi:10.1016/j.jsams.2018.05.003
8. Hou S, Chiu Y, Tsai Y, et al. Clinical Impact of Speed Variability to Identify Ultramarathon Runners at Risk for Acute Kidney Injury. PloS One. 2015;10(7). doi:10.1371/journal.pone.0133146