NSAIDs (Ibuprofen/Acetaminophen) for runners, impairs healing and interferes with hydration

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NSAIDs are Non-Steroidal Anti-Inflammatory Drugs, the most common are Ibuprofen (Advil, Motrin), Acetaminophen (Tylenol, aspirin-free Anacin, Excedrin, and numerous cold medicines) and Aspirin. They work by inhibiting a particular enzyme ([1]) which reduces pain, fever and inflammation. NSAIDs are generally bad for runners, impairing healing, masking symptoms, interfering with hydration and in extreme situations can be life threatening. Ibuprofen use is so common among runners that it is sometimes called "Vitamin I"[1].

1 NSAIDs and Healing

The inflammation response of our bodies is a key part of the healing process. Using NSAIDs to reduce the inflammation has been shown to impair healing in different tissue types:

  • Muscles. [2]. A 2001 study showed that Ibuprofen and Acetaminiaphen reduce muscle growth after eccentric exercise. Another study[3] on muscle damage and NSAIDs showed impaired recovery in the early stages of healing. There was some increased protein synthesis with NSAIDs in latter stages of healing, but the muscles were still weaker 28 days after injury. Other studies[4][5] have shown that four days after injury, NSAIDs resulted in very little muscle regeneration compared with no drugs.
  • Tendons. A primate study[6] showed "a marked decrease in the breaking strength of tendons at four and six weeks in the ibuprofen-treated animals". Another animal study[7] showed treated tendons were 32% weaker than their untested counterparts.
  • Bone-Tendon Junctions. An animal study[8] of rotator cuff injuries shows that NSAID usage resulted in injuries that did not heal, and those that did heal were weaker than those without NSAID. To quote from the study "Given that NSAID administration was discontinued after 14 days yet affected load-to-failure eight weeks following repair, it appears that inhibition of the early events in the inflammatory cascade has a lasting negative effect on tendon-to-bone healing," Dr. Rodeo said.
  • Cartilage. NSAIDs have been shown[9] to impair the healing of bone and cartilage in rabbits.
  • Bone fractures. Tests on rats shows that a NSAID (Celecoxib) in the early stages of bone healing impaired healing, producing a weaker repair.[10] A study [11] in 2004 declared " Nonsteroidal anti-inflammatory drugs continue to be prescribed as analgesics for patients with healing fractures even though these drugs diminish bone formation, healing, and remodeling".

1.1 Counterpoint

While there is extensive experimental evidence for NSAIDs impairing healing, there are also some studies that show no change with NSAID use, and a few that indicated improved healing. For instance, one study[12] showed that using an NSAID for 6 days after injury resulted in a 42% increased ligament strength at day 14, though there was no change by day 21. Another study[13] showed that an NSAID did not change ligament healing, but did improve the strength of the uninjured ligaments. However, my reading indicates that the preponderance of evidence shows NSAIDs impair healing.

1.2 Ice, Inflammation and Healing

If NSAIDs are bad for healing, should we treat with ice? So far I have found no definitive studies, but ice has a difference mechanism of action from NSAIDs. By cooling the tissues, ice temporarily reduces inflammation, thereby flushing the wound. It does not directly impact any of the body's enzymes or other processes. If applied for a longer period of time, ice will produce a periodic increase in blood supply that creates a further flushing effect. I have found that ice can produce dramatic improvements in healing speed. See Cryotherapy - Ice for Healing for more details.

2 NSAIDs and Hyponatremia

To follow.

3 NSAIDs and racing

To follow.

4 Longer Term NSAID usage

Using NSAIDs for longer periods of time can lead so some serious problems. A running friend had a bleeding ulcer from using Ibuprofen, which is a known [14] side effect. The likelihood of a bleeding or perforated ulcer goes up with time, from 1% after 3-6 months, to 2-4% after 12 months. (Taking a Ibuprofen/Famotidine combination has been shown[15] to reduce the incidence gastric ulcers from 35% to 14% in longer term users.) Acetaminophen does not have the same risk of ulcers, but it is linked to liver damage, especially in those who drink alcohol. Acetaminophen is the leading cause of acute liver failure[16]. There are concerns that even the standard dose can cause changes in liver function. [17]

5 Tangent - Is Acetaminophen really an NSAID?

There are differing opinions around the classification of Acetaminophen as an NSAID with some resources[18] stating it is not an NSAID. While Acetaminophen has limited anti-inflammatory properties, it shares the same mechanism of action with most NSAIDs of inhibiting the COX enzyme and the inhibition of prostaglandin synthesis. It is therefore reasonable and useful to classify Acetaminophen as an NSAID.

6 References

  1. ↑ Urban Dictionary: Vitamin I http://www.urbandictionary.com/define.php?term=Vitamin%20I
  2. ↑ Skeletal Muscle PGF2αand PGE2 in Response to Eccentric Resistance Exercise: Influence of Ibuprofen and Acetaminophen http://jcem.endojournals.org/content/86/10/5067.long
  3. ↑ An In Vitro Investigation Into the Effects of Repetitive Motion and Nonsteroidal Antiinflammatory Medication on Human Tendon Fibroblasts http://ajs.sagepub.com/content/23/1/119
  4. ↑ Cost-conscious prescribing of nonsteroidal anti-in... [Arch Intern Med. 1992] - PubMed result http://www.ncbi.nlm.nih.gov/pubmed/1417372
  5. ↑ Sports Injuries - NSAIDs: Why We Do Not Recommend Them http://www.caringmedical.com/sports_injury/nsaids.asp
  6. ↑ Oral ibuprofen: evaluation of its effect on peritendinous adhesions and the breaking strength of a tenorrhaphy. [J Hand Surg Am. 1986] - PubMed result http://www.ncbi.nlm.nih.gov/pubmed/3511134#
  7. ↑ A cyclooxygenase-2 inhibitor impairs ligament heal... [Am J Sports Med. 2001 Nov-Dec] - PubMed result http://www.ncbi.nlm.nih.gov/pubmed/11734496?dopt=Abstract&holding=npg
  8. ↑ NSAIDs Inhibit Tendon-to-Bone Healing in Rotator Cuff Repair http://www.shoulderdoc.co.uk/article.asp?article=295
  9. ↑ Effect of ibuprofen on the healing and remodeling of bone and articular cartilage in the rabbit temporomandibular joint http://www.joms.org/article/0278-2391%2892%2990276-6/abstract
  10. ↑ JBJS | Dose and Time-Dependent Effects of Cyclooxygenase-2 Inhibition on Fracture-Healing http://www.jbjs.org/article.aspx?Volume=89&page=500
  11. ↑ Effects of Nonsteroidal Anti-Inflammatory Drugs on Bone Formation and Soft-Tissue Healing -- Dahners and Mullis 12 (3): 139 -- Journal of the American Academy of Orthopaedic Surgeons http://www.jaaos.org/cgi/content/abstract/12/3/139
  12. ↑ The effect of a nonsteroidal antiinflammatory drug... [Am J Sports Med. 1988 Nov-Dec] - PubMed result http://www.ncbi.nlm.nih.gov/pubmed/3239621?dopt=Abstract&holding=npg
  13. ↑ The influence of a cyclooxygenase-1 inhibitor on i... [Am J Sports Med. 2003 Jul-Aug] - PubMed result http://www.ncbi.nlm.nih.gov/pubmed/12860547
  14. ↑ Ibuprofen Official FDA information, side effects and uses. http://www.drugs.com/pro/ibuprofen.html
  15. ↑ Ibuprofen/Famotidine Reduces Gastric Ulcer Incidence http://www.medscape.com/viewarticle/732432
  16. ↑ Acetaminophen-induced acute liver failure: Results of a United States multicenter, prospective study - Larson - 2005 - Hepatology - Wiley Online Library http://onlinelibrary.wiley.com/doi/10.1002/hep.20948/pdf
  17. ↑ FDA May Restrict Acetaminophen http://www.webmd.com/pain-management/news/20090701/fda-may-restrict-acetaminophen
  18. ↑ ACETAMINOPHEN (PARACETAMOL) http://www.chemicalland21.com/lifescience/phar/ACETAMINOPHEN.htm
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