◆
TREATING THE ATHLETE
◆
on the market to discuss here. However, the following are prescribed frequently: • Acetaminophen with codeine (Tylenol® No. 3): This drug product combines 300 mg of acetaminophen with 30 mg of codeine. It is strictly an analgesic and thus has no antiinflammatory effects. • Acetaminophen with oxycodone (Percocet®, Tylox®): These two ingredients are available in several different strength combinations. Like Tylenol No. 3, this product serves only as an analgesic with no anti-inflammatory effects. • Hydrocodone with ibuprofen (Vicoprofen®): This drug product combines 7.5 mg of hydrocodone with 200 mg of ibuprofen. It is an excellent choice for moderate to severe pain when an oral medication is needed, for example, in the management of pain associated with a broken bone.
Generally, problems stemming from the chronic use of aspirin and NSAIDs will be seen in the GI tract: epigastric pain, GI bleeding, or liver damage. Chronic use of acetaminophen raises the possibility of liver toxicity, and chronic use of opiates can lead to dependence. CONTRAINDICATIONS
Along with knowing what works well, it’s just as important to know when a drug is contraindicated. Aspirin and NSAIDs should NOT be used in the following situations: Undiagnosed abdominal pain or a history of blood in the stool: Anyone, even perfectly healthy athletes, can develop gastritis by taking too 22 ◆ T & C O C T O B E R 2 0 0 4 ◆
much aspirin or NSAIDs. Some evidence shows that strenuous exercise itself, such as marathon running, can cause GI bleeding, so adding one of these drugs only increases that risk. Most often, this is not a serious problem and recovery is prompt if the offending agent is discontinued. For athletes who have had epigastric pain after taking aspirin or an NSAID and who need an occasional dose of a mild analgesic, acetaminophen (such as Tylenol®) is safer. Alcohol should be avoided while taking aspirin or NSAIDs since the combination may have additive erosive effects on the stomach lining. Any kind of bleeding problem: This warning always applies to drugs like aspirin and NSAIDs because of their effects on platelet function, but generally, the medical conditions that generate this kind of warning are highly uncommon in athletes. If, however, an athlete develops easy bruising while taking aspirin, discontinue use and consult a physician. Athletes in this situation who need an occasional dose of a mild analgesic should use acetaminophen instead. In addition, if an athlete is bleeding from a laceration, aspirin or NSAIDs should not be administered due to their effects on platelet function. Liver disease: All types of analgesics discussed here (aspirin, NSAIDs, acetaminophen) have the potential for causing liver damage. Fortunately, this is not very common with occasional use of any of these drugs. Acetaminophen, however, is slightly different. Athletes should not use this drug in high doses (more than 2,400 mg/day) or take it chronically as this increases the risk of liver toxicity. Regular consumption of alcohol and acetaminophen together also increases the risk of liver damage. Asthma, history of aspirin sensitivity, or allergy to tartrazine dye: This warning is one that always appears in the literature, but fortunately, problems are very rare. Nevertheless, if your athlete is asthmatic, you should question him or her about shortness of breath and any allergies to aspirin, NSAIDs, or any other drugs before administering medications.
ATHLETICBID.COM
Concussion or altered mental status: If an athlete has just sustained a concussion or is exhibiting anything other than a clear mental state, drugs should not be administered. If the athlete loses consciousness after taking a dose of medication, making an accurate diagnosis is more difficult. DOSING
With the dozens of available drug products that include an NSAID component, specific dosing information is well beyond the scope of this article. Instead, I will address general questions about dosing these drugs. What are the short-term limits of taking NSAIDs? When managing DOMS or simple joint aches not related to a specific injury, NSAIDs can be used for several days, up to a week or two. If the problem does not resolve, the athlete should rest the affected area—using a higher dose or switching to a more potent drug will just cover up the problem. For management of fever or headache, NSAIDs should not be continued for more than three days. If the fever or headache doesn’t go away quickly, the athlete should be referred to a physician. What are the long-term limits? Considering that patients with rheumatoid arthritis take NSAIDs for years and years, these drugs are relatively safe. However, possible long-term effects should not be ignored. The risk of toxicity and side effects is determined somewhat by frequency of use. If an otherwise healthy athlete takes one or two ibuprofen tablets once a week for an entire season, it is highly unlikely that he or she will develop any long-term toxicities. However, anyone who takes any of the drugs discussed here daily for months could, and probably will, develop problems. Generally, problems stemming from the chronic use of aspirin and NSAIDs will be seen in the GI tract: epigastric pain, GI bleeding, or liver damage. Chronic use of acetaminophen raises the possibility of liver toxicity, and chronic use of opiates can lead to dependence.