Sports Medicine: Just the Facts

CHAPTER 70 • MEDICATIONS AND ERGOGENICS 417

inhibitors or nonselective NSAIDs (Mukherjee,

2001).

STRATEGIES TOLIMITSIDEEFFECTS

• Limit amount and duration.
  •Use alternative medication (e.g., acetominophen).
  •Use alternative modality for pain control (e.g., ice,
  electrical stimulation).


• Since GI ulceration is the most common serious side
  effect, most strategies have focused on reducing this
  complication.
  •H 2 blockers are largely ineffective except for per-
  haps duodenal ulcers.
  
  
  • The role of sucralafate is not well defined.
  
  
  • In a small study performed in Hong Kong, coad-
    ministration of proton pump inhibitors(PPIs) with
    conventional NSAIDs reduced recurrent NSAID-
    associated upper GI bleeding (Schoenfeld, 2001).
  
  
  • Although there is no data currently to support coad-
    ministration of PPIs with COX-2-selective NSAIDs,
    it should be considered for patients with multiple
    risk factors for serious NSAID-associated GI disor-
    ders (Schoenfeld, 2001).
  
  
  • Misoprostol, a PGE1 analog, has been shown to decre-
    ase ulcers and serious GI complication rates up to
    40%. It is cost effective in high risk groups, those over
    75 with previous ulcer disease, but is not very cost
    effective in the typically younger otherwise healthy
    athlete (Maetzel, Ferraz, and Bombadier, 1998).
  
  
  • Use of COX-2 inhibitors.
    a. When choosing a COX-2 NSAID to reduce seri-
    ous NSAID-associated GI complications, stronger
    evidence indicates that rofecoxib reduces serious
    NSAID-associated GI complications compared
    with conventional NSAIDs (Schoenfeld, 2001).
    b.However, patients receiving celecoxib do not show
    a statistically significant reduction in serious
    NSAID-associated GI complications compared
    with patients receiving ibuprofen or diclofenac
    unless aspirin use was eliminated (Schoenfeld,
    2001).
    c. It is not known how other NSAID effects (such as
    that on kidneys, brain and platelets) will be mod-
    ified by the use of COX-2 inhibitors, and what
    new toxicities will be experienced until the post-
    marketing reporting and long-term follow-up
    studies are performed.
  
  
  
  


• Use topical preparations of NSAIDs.
  •Topical NSAIDs have serum drug levels of only
  about 10% of oral medication while showing equiv-
  alent tissue concentrations.
  •A meta-analysis of 86 trials using up to 2 weeks of
  treatment concluded that topical nonsteroidals are
  effective in relieving pain in both acute and chronic

conditions and have a low incidence of local side

effects with systemic side effects no different than

placebo (Moore et al, 1998).

CORTICOSTEROIDS

MECHANISM OFACTION

• Corticosteroids are a class of medications acting on a
  number of body systems including inflammation.
  Glucocorticoids downregulate the expression of
  inflammatory genes in cells, thus decreasing inflam-
  matory cytokines, enzymes, and adhesion molecules,
  while upregulating the production of anti-inflamma-
  tory proteins such as interleukin-1 receptor antagonist
  and interleukin-10.

RAT I O NALE FORUSE

•Can be given via various routes including orally, by

injection, or transdermally through the use of creams—

iontophoresis or phonophoresis.

• Although commonly used for a variety of acute and
  chronic injuries, most of the literature evaluating
  steroids for treating sports medicine injuries is retro-
  spective in nature, case series, or anecdotal.
  
  
  • Acute injuries.
    a. The literature has no prospective studies that eval-
    uate the effectiveness of steroids in treating acute
    injuries. Anecdotally, some clinicians use short
    courses of oral steroids from 3–5 days on acute
    injuries including radicular back pain, but this has
    not been evaluated prospectively. Because of the
    potential side effects from steroid use, treatment
    with corticosteroids for acute injuries in the sports
    setting should be of short duration and left up to the
    individual clinician to develop any treatment proto-
    col until better information becomes available.
  
  
  • Chronic overuse injuries
    a. Although many chronic tendon injuries seem to be
    a tendonosis of a degenerative nature and do not
    involve classic chronic inflammatory cells, clini-
    cians frequently use corticosteroids for these con-
    ditions, which often provide the patient with
    temporary pain control (Almekinders and Temple,
    1998).
    b.The effectiveness of steroids in chronic injuries has
    not been well investigated by prospective trials.
    c. Overall, the literature suggests that if steroids are
    used to treat chronic sports injuries, they should
    be considered a pain control method.
  
  
  
  

SIDEEFFECTS ANDCOMPLICATIONS

• Steroid injection has a low complication rate of 1–2%.
  
  
  • Hypopigmentation and fat pad atrophy are the most
    common long term ill effects.