NSAIDs in sport

Non-steroidal anti-inflammatory medicine, or NSAIDs, can scale back ache sensations. In a previous blog, we mentioned the mechanisms of NSAIDs motion. This weblog discusses the use, in addition to contraindications to the usage of NSAIDs in an athletic area. When utilized in a sport setting, akin to throughout endurance working, NSAIDs can compromise intestine integrity, kidney operate and cardiovascular well being. Regardless of these dangers, many athletes nonetheless use them. Beneath we define the dangers and describe why it’s best to keep away from NSAIDs throughout sport.

I’ve run a bunch of marathons and ultras in my time. It’s uncommon to see NSAIDs at an assist station alongside the jellybeans and sausage rolls, and but it occurs. That’s proper, as runners had been grabbing handfuls of crisps and tipping water on their heads, additionally they had the choice of popping a number of drugs from an open packet of ibuprofen. I’ve seen it twice, to be precise, in races I contested some years in the past. And it’s twice too many.

You wouldn’t get away with it at this time. Main working organisations like Extremely Path du Mont Blanc (UTMB) have banned NSAIDs in competitors, whereas others, such because the London Marathon and Western States Endurance Run (WSER), strongly discourage their use throughout occasions and for 48 hours earlier than and after. Sports activities medics hardly ever prescribe NSAIDs anymore, even for accidents (1). And for good motive, which we’ll get to shortly.

And but, our collective NSAID behavior isn’t going wherever. One research discovered ibuprofen within the urine of twenty-two% of runners at UTMB (earlier than the ban was imposed) (2), and one other reported that 67% of runners use NSAIDs earlier than, throughout, or after races from 10K to marathon (3). Regardless of the warnings, many athletes nonetheless pack NSAIDs with their gels, bibs, and blister tape. So, what are NSAIDs? And why are you being advised to keep away from them in races?

As we mentioned in a previous blog, NSAIDs are artificial medicine that block prostaglandins, that are concerned in irritation and the sensitisation of ache receptors. Extra particularly, NSAIDs inhibit cyclooxygenase (COX) enzymes (COX-1 and COX-2) that are answerable for prostaglandin manufacturing. Briefly, NSAIDs inhibit the manufacturing of COX, block prostaglandins, and attenuate irritation and ache. They’re not banned by WADA (the World Anti-Doping Company) as a result of they’re not performance-enhancing, per se, however fairly performance-enabling, permitting you to carry out by means of the ache. When your physique sounds the alarm bells as a consequence of muscle injury or harm, NSAIDs successfully scale back the quantity. That will sound like a bonus, nevertheless it’s a harmful phantasm.

Inhibiting COX enzymes doesn’t simply have an effect on ache: COX play an essential position in intestine safety, blood clotting, kidney perfusion, and cardiovascular well being. Popping NSAIDs triggers a domino impact that begins with suppressing ache and irritation however ends with a cascade of unintended penalties.

COX enzymes defend the abdomen lining by selling mucus and bicarbonate secretion. NSAIDs compromise this, damaging the abdomen lining and probably resulting in irritation, ulceration, and bleeding. The truth is, a 3rd of sufferers consuming NSAIDs complain of gastrointestinal (GI) points, and as much as 70% of these taking them long-term have extreme GI uncomfortable side effects (1). Don’t overlook that train additionally strains the GI tract by forcing it to compete with muscle mass for restricted blood provide. This will increase the possibilities of GI upset, which is a typical motive for DNFs throughout marathon and ultra-marathon. The truth is, athletes who take NSAIDs earlier than a marathon could also be extra prone to withdraw as a consequence of GI complaints.

Strenuous train places appreciable stress on the renal system. Dehydration, electrolyte imbalances, and excessive core temperatures – all widespread points in endurance sport – improve load on the kidneys. On the identical time, the kidneys should filter out metabolic waste, together with muscle metabolites and myoglobin which will leak into the blood as a consequence of muscle injury. Throughout competitors, the kidneys are already in a precarious place. NSAIDs make issues worse by additional lowering renal blood move by means of COX inhibition. Taking NSAIDs pre- or mid-race is like sucker-punching your kidneys after they’re already on the ropes, considerably growing the chance of acute kidney harm.

No physique system works in isolation, least of all of the kidneys. The cardio-renal axis refers back to the interconnectedness between the kidneys and the guts. It signifies that injury to at least one organ can have an effect on the opposite in myriad methods. If the kidneys are over-taxed, extra fluid accumulates within the physique, elevating blood stress and straining the guts. If the guts can not modify to the quantity overload, fluid can construct up within the lungs, probably resulting in a severe situation known as pulmonary oedema. Inhibiting COX enzymes and prostaglandins by taking NSAIDs causes sodium and water retention, which additional exacerbates blood stress, forcing the guts to work more durable. All of it raises the possibilities of myocardial harm.

In a research of almost 4,000 marathon runners, those that took aspirin or ibuprofen earlier than the race had been extra prone to undergo adversarial occasions together with three who had been hospitalised for kidney failure, 4 for GI bleeds, and two for cardiac infarctions (4). And a report from the 100-mile Western States race discovered that runners who had simultaneous rhabdomyolysis and hyponatremia had been extra prone to have used NSAIDs (5). These runners invariably had kidney injury and severe cardiopulmonary issues, requiring dialysis and prolonged hospital stays. Endurance train strains the physique and challenges homeostasis in a number of methods. NSAIDs exacerbate the dangers tenfold.

In the event you’re searching for ache aid or irritation management round train, there are safer, albeit maybe much less potent, options to NSAIDs. Topical NSAIDs like diclofenac (the energetic ingredient in Voltarol) could be utilized on to painful muscle mass and joints, concentrating on the location of discomfort whereas minimising systemic absorption. This reduces (though doesn’t eradicate) the chance of gastrointestinal, renal, or cardiovascular uncomfortable side effects related to oral NSAIDs (3).

Chilly remedy stays a low-tech however efficient possibility. Ice will help blunt peripheral ache indicators and scale back native irritation, although repeated utility is required to maintain the impact. And whereas it will not speed up restoration, it might enhance consolation sufficient to permit gentle exercise.

Then there’s cannabidiol, or CBD, the wellness trade’s newest money cow. CBD is broadly promoted for ache aid, irritation, and restoration, typically added to balms, roll-ons, or oils. However regardless of the hype, many of the proof is weak or inconsistent (see a previous blog on CBD). The place advantages are reported, placebo results doubtless play a serious position. And there is one other wrinkle: many CBD merchandise are poorly regulated. An impure formulation could comprise undisclosed or variable ranges of THC (the psychoactive compound in hashish that is banned in sport). So, you is perhaps smearing your quads with a placebo when you’re fortunate and a banned substance when you’re not. You’ve got been warned.

Simply over a decade in the past, as much as 93% of endurance runners had been naïve to the contraindications of NSAIDs (4). I sincerely hope that’s an outdated statistic. Schooling on the dangers is, due to this fact, essential. All medical interventions – medicine, procedures, and gadgets – include dangers, and well being professionals are educated to rigorously steadiness the dangers towards the rewards. More and more, although, specialists are concluding that the dangers of NSAIDs usually are not justified by the advantages. Nowhere is that this extra obvious than throughout endurance train, when the kidneys are already below appreciable pressure.

Given the potential hurt of NSAIDs, WADA would possibly contemplate altering their standing. In spite of everything, medicine aren’t banned solely as a result of they violate the spirit of honest play, but in addition as a result of they’re unsafe. The rising physique of proof means that NSAIDs match this description. Endurance racing is already a struggle of attrition. And whereas NSAIDs would possibly make it easier to transiently ignore ache, additionally they improve your possibilities of a DNF, or worse, a go to to A&E. Throughout train, NSAIDs add gasoline to the fireplace. Don’t get burned.

1. Tai FWD, McAlindon ME. Non-steroidal anti-inflammatory medicine and the gastrointestinal tract. Clin Med. 2021;21(2):131-134. doi:10.7861/clinmed.2021-0039

2. Robach P, Trebes G, Buisson C, et al. Prevalence of Drug Use in Ultraendurance Athletes. Med Sci Sports activities Exerc. 2024;56(5):828-838. doi:10.1249/MSS.0000000000003374

3. Derry S, Conaghan P, Silva JAPD, Wiffen PJ, Moore RA. Topical NSAIDs for power musculoskeletal ache in adults – Derry, S – 2016 | Cochrane Library. Accessed Might 24, 2025. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD007400.pub3/full

4. Küster M, Renner B, Oppel P, Niederweis U, Brune Okay. Consumption of analgesics earlier than a marathon and the incidence of cardiovascular, gastrointestinal and renal issues: a cohort research. BMJ Open. 2013;3(4):e002090. doi:10.1136/bmjopen-2012-002090

5. Pasternak AV, Newkirk-Thompson C, Howard JH, Onate JC, Hew-Butler T. 4 Instances of Acute Kidney Harm Requiring Dialysis in Ultramarathoners. Wilderness Environ Med. Revealed on-line February 15, 2023:S1080-6032(22)00219-8. doi:10.1016/j.wem.2022.12.004