5. Mitteldeutscher Schmerztag 2014

Transcription

5. Mitteldeutscher
Schmerztag 2014
Hausarzt und Spezialist:
Gemeinsam gegen den Schmerz
Programm
Freitag, 28.11.2014 (Ärzte)
0930–1000
Besuch der Industrieausstellung und
Anmeldung zur Tagung
1000–1130
Fachseminar: Aktuelle Themen
Großer Saal
Vorsitz
W. Meißner (Jena)
U. Richter (Chemnitz)
1000
Naturheilkundliche Möglichkeiten bei
Schmerzpatienten
D. Jaenichen (Jena)
1030
Analgetika im Sport – eine unterschätzte
Gefahr?
H. Gabriel (Jena)
www.mitteldeutscher-schmerztag.de
1100
Diskussion
28.–29. November 2014
1130–1215
Besuch der Industrieausstellung und
Anmeldung zur Tagung
© Martina Berg
Neue Weimarhalle • WEIMAR
Aktualisiertes Programmheft
1215–1255
Eröffnung des 5. Mitteldeutschen Schmerztages
Großer Saal
1215
1230
Grußwort der Wissenschaftlichen Leitung
Dr. med. Ingo Palutke
Univ.-Prof. Dr. med. Holger Gabriel
Lehrstuhl für Sportmedizin und Gesundheitsförderung
der
Friedrich-Schiller Universität Jena
Grußwort der 1. Vorsitzenden
Kassenärztlichen Vereinigung Thüringen
Analgetika im Sport - eine unterschätzte Gefahr?
es
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5. Mitteldeutscher
Schmerztag 2014
Move!Pro!Health
Bewegung, Übung, Training, Sport und Altern
Kolloquium(Sports(Medicine(
VLauf
PRad
[km/h]
[W/kg]
.noisses sisylaid a fo sruoh 2 tsrfi eht gnirud gnilcyc tneitap dlo-raey-ythgiE .1 .giF
MAX
IAS
MAX
IAS
Spitzensport
30
20
6
Leistungssport in
Ausdauersporten
25
5
Leistungssport in
Spielsportarten
15
4
3
20
4
15
Wettkampfsport
gesund untrainiert
10
3
NYHA / CCS Class I
10
Übergang Gehen/Laufen
Freies Treppensteigen
2
NYHA / CCS Class II
Trainieren
5
1
1 Etage Treppensteigen
5
Üben
1
NYHA / CCS Class III
Selbstversorgungsgrenze
NYHA / CCS Class IV
passive
Bewegungen
0
Sitzen, Liegen
Bettlägerigkeit
0
0
20
0
40
60
Alter [Jahre]
Friedrich-Schiller-University of Jena
Sports Medicine and Health Promotion
2
80
100
0
Beanspruchung durch Belastung
Objektive Beobachtung
Subjektive Wahrnehmung / Bewertung
Hirnfunktionen
Zentrale Aktivierung / Ermüdung
Autonomes Nervensystem
Temperaturerhöhung / Schwitzen
HHA-Achse
Atmung
Bewegung / Funktion / Wirkung
Ventilation / Dyspnoe
Herz-Kreislaufsystem
Herzschlag / Palpitationen
Gastrointestinaltrakt
Pulserhöhung / -rhythmus
Zelluläre Immunfunktionen
Inflammatorische Regulation
Energiestoffwechsel
Muskuläre Schädigung
Reparaturprozesse
Knochen / Knochenmark
Schmerz
Verfärbung
Muskuläre Ermüdung /
Funktionsstörung
Schwellung
DOMS
(Delayed onset of muscle soreness)
Körperliche Belastung wirkt
pro- und antiinflammatorisch,
schmerzinduzierend und analgetisch.
340 7 Sportmedizin
Sport tut weh. Nicht nur, aber auch!
Supraspinatus-Syndrom
(Kugelstoßen)
Schmerzen endogener Ursache
Korakoiditis
(Delphinschwimmen)
Schmerzen exogener Ursache
Schädel-Hirn-Trauma
DOMS
Überlastungsschäden
Hämatome
Verletzungen des HBS
Offene Verletzungen
Epicondylitis ulnaris
(Gewichtheben,
Speerwurf)
n
e
z
r
e
7 hm
c
Karpaltunnel-Syndrom
(Klettern)
Bindegewebsverletzungen
Ischämien
Infektionen
Kälte-/Hitzeschäden
Physikalisch induzierte Schäden
nS
t de
Stich-/Pfählungsverletzungen
i
m
n
Bizeps-Tendinitis
(Golf)
?
m
u
Epicondylitis
radialis
(Tennis)
Bursitis olecrani
(Torwart)
jammed finger
(Volley-, Basketball)
Skidaumen
(Skifahren)
Knochen-/Knorpelverletzungen
Metabolisch induzierte Schmerzen
a
m
ht
Muskelverletzungen
e
i
W
ge
Meniskusschäden
(Fußball)
Heberden-Arthrose
(japanischer
Kampfsport)
Chondropathia
patellae
(Fußball)
Verletzungen der Gelenke
Allergische Inflammation
Adduktoren-Tendopathie
(Fußball)
Umweltbedingungen
Innenbandschäden
(Brustschwimmen)
jumper´s knee
(Springen)
Außenbanddehnung
(Lotussitz)
Kleidung, Ausrüstung
Pes-anserinus-Syndrom
Berg(ab)steigen
Körperliche Belastung wirkt
pro- und antiinflammatorisch,
schmerzinduzierend und analgetisch.
chronischer Verstauchungsfuß
(Volley-, Basketball)
Achillodynie
(Laufen)
Tendinitis der Zehenextensoren (Gehen,
Laufen)
Abb. 7.1 Sportverletzungen
Horstmann T, Nieß A: Sportmedizin. In: Praxisleitfaden Allgemeinmedizin. Hrsg.: Gesenhues S,
Ziesché RH, Breetholt. Elsevier, 2014, S. 322
7.1.6
Muskelverletzungen und -erkrankungen
Myogelosen
Friedrich-Schiller
Universität
Jena
Stoffwechselentgleisung in vorwiegend statisch beanspruchten
Muskeln
mit reaktiver muskulärer Verhärtung.
Definition
Zovirax Augensalbe
Rp
Sonstige Mittel z.B.
Bepanthen Augen- und Nasensalbe
Cerumenex N
Hylo Comod
Vidisept 2%
16
Augentropfen gegen allergische
Konjunktivitis, z.B. Heuschnupfen,
siehe unter „Allergien, Heuschnupfen“
Limptar N
Musaril
Mydocalm
Ortoton
5. Bakterielle Infekte (Antibiotika)
Alle Präparate, die ausschließlich Antibiotika als Wirkstoffe enthalten
14Rp
6. Bronchitische Beschwerden, Husten
Beispielliste zulässiger Medikamente 2013
Sodbrennen / Gastritis / Duodenitis
Durchfall und Verstopfung
Rp
Rp
Rp
Nationale Anti Doping Agentur Deutschland (Hrsg.)
BEISPIELLISTE
ZULÄSSIGER
MEDIKAMENTE 2013
Spondyvit
Tetrazepam
Zeel
Nichtsteroidale Antirheumatika
Sonstige Schmerzmittel z.B.
Ambene
Buscopan
Contraneural
Demex
Dolomo TN
Katadolon (S long)
Lyrica
Paracetamol
Piroxicam
Rantudil
Tramadol
Valoron N
,
r
e
t
n
i
z
r
a
r
a
T
t
r
r
o
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p
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r
,
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n
i
d
r
e
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e
,
n
i
n
i
a
t
r
z
T
r
ä
e
t
d por
e
j
,
t
S
e
l
e
th jed
A
r
,
e
n
i
d när
e
j
,
o
i
n
i
t
t
k
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t
F
A
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,
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t
ä
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n
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o
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i
t
K
k
un
BEISPIELLISTE
F
e
ZULÄSSIGER
d
19. Stoffwechselstörungen (Lipidsenker)
e
Schleimlöser z.B.
ACC / NAC
Acetylcystein
Ambroxol
Aspecton DS
Bromhexin
Bronchoverde
Fluimucil
Melrosum
Mucosolvan**
z. T. Rp
z. T. Rp
Loperamid z.B.
Imodium
Lopedium
Sedotussin Hustenstiller
Silomat DMP
Silomat gegen Reizhusten
z.T. Rp
z.T. Rp
Bronchicum
Bronchipret
Bronchoforton
GeloMyrtol
Pinimenthol
Prospan
Sinupret
Soledum
Transpulmin
Umckaloabo
Agiocur
Agiolax
z. T. Rp
Dulcolax
Elotrans
Glycilax
Hustenstiller z.B.
Bronchicum Mono Codein
Rp
Hylak N / plus acidophilus
Capval
Rp
Kohle-Hevert
Codicaps mono
Rp
Kohle-Tabletten
Paracodin N
Rp
Laxoberal
Macrogol
11
Mediolax
Metifex
7. Gallen- und Nierenkoliken
Movicol
Mucofalk
z.B.
Cholspasmin forte 400 mg
Buscopan
Nitrolingual
Rp Neda Früchtewürfel
Omniflora
Perenterol
8. Grippale Infekte, Fieber und Schnupfen
Tannacomp
Tannalbin
Schnupfenmittel
Nasentropfen/-sprays gegen
(Nasentropfen und -spray)
allergische Rhinitis, z.B. Heu- Tirgon
Xylometazolin z.B.
Nasenspray / -tropfen ratiopharm
Nasic
Olynth
Otriven
weitere Mittel mit vergleichbaren
Inhaltsstoffen z.B.
Nasivin
Rhinospray
Coldastop NTR SN
Emser Nasenspray
Euphorbium comp.
Nasic cur
j
schnupfen, siehe unter „Allergien,
Heuschnupfen“
Interna
Aspirin (plus C)
ASS
Ben-u-ron
Contramutan (D/N)
Dolviran N
Gelonida
Gripp-Heel
Grippostad C
Ibuprofen
Paracetamol
Paracetamol comp.
Thomapyrin
Übelkeit und Erbrechen
Metoclopramid z.B.
MCP
Paspertin
Aequamen
Iberogast
Motilium
Scopoderm TTS
Rp Vomacur
Vomex A
Rp
Rp
9. Hauterkrankungen (inkl. Nagelerkrankungen)
Rp
Rp
Rp
Rp
Rp
z.B.
Antra
z.T. Rp
Famotidin
Rp
Gastrozepin 50
Rp
Gaviscon Advance Pfefferminz
Gelusil Lac
Kompensan
Maalox
Maaloxan
Nexium
Rp
Omep
z.T. Rp
Omeprazol
z.T. Rp
Pantozol
z.T. Rp
Pepciddual
Ranitidin
z.T. Rp
Rifun
z.T. Rp
Riopan
Talcid
Ulcogant
Rp
Zantic
Rp
Sonstige Magen-DarmTherapeutika
z.B.
Buscopan
Claversal
Enzym-Lefax
Hepa-Merz Granulat
Kreon
Lefax
Meteozym
Pankreatin
Pankreoflat
sab simplex
Salofalk
Rp
18. Schmerzen (inkl. Migränemittel)
14. Magen- und Darmbeschwerden
**Achtung: Spasmo Mucosolvan mit dem Wirkstoff Clenbuterol ist
verboten!
Rp
Acetylsalicylsäure z.B.
Aspirin
ASS
Diclofenac z.B.
Arthotec forte
Effekton
Rewodina
Voltaren
Rp
Rp
Rp
z.T. Rp
Ibuprofen z.B.
Dismenol N
Dolgit
Dolormin
Optalidon Ibu 200 mg
Tispol Ibu DD
Ketoprofen z.B.
Alrheumun
Gabrilen
Rp
Rp
Metamizol z.B.
Novalgin
Novaminsulfon
Rp
Rp
Naproxen z.B.
Dolormin für Frauen
Dolormin GS
Migränemittel z.B.
AscoTop
Ergo-Kranit Migräne
Formigran
Maxalt
Migränerton
Topamax
Topiramat
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Rp
Externa
siehe akute Verletzungen
Nationale Anti Doping Agentur Deutschland (Hrsg.)
Rp
z.B.
Bezafibrat
MEDIKAMENTE 2013
Rp
Colestyramin
Eicosan
Rp
(z.B. Hautinfektionen durch Bakterien, Viren und Pilze einschl. Akne;
Juckreiz und Ekzeme; Hämorrhoidenmittel, Wundbehandlungsmittel)
* Die gekennzeichneten Medikamente enthalten Kortison. Bitte geben
Sie insbesondere die Anwendung dieser Medikamente bei Dopingkontrollen immer an!
z.B.
Aknemycin
Rp
Amorolfin
Ampho-Moronal
Rp
phage concentration than the placebo rats exposed to
the exercise.[63] Two weeks later the injurious exercise was repeated, and the rats treated with NSAIDs
showed
greater force deficits and macrophage conLEADING ARTICLE
centrations than the placebo rats. Although these
few animal studies suggest that inflammation may
play an integral role in the adaptation of muscle to
Use ofand
Nonsteroidal
exercise
that NSAIDs may interfere with this
adaptation,
it is not known whether
is the case
Anti-Inflammatory
DrugsthisFollowing
for
humans.
Exercise-Induced
Muscle Injury
Histological analysis of EIMI has provided addiAngela Baldwin Lanier
tional
support for the efficacy of NSAIDs for EIMI,
Department of Health, Physical Education and Sport Science, Kennesaw State University,
after naproxen sodium therapy for EIMI found that
strength and magnetic resonance images were fully
recovered (Baldwin Lanier, unpublished observations).
Sports Med 2003; 33 (3): 177-186
0112-1642/03/0003-0177/$30.00/0
Trainings- und Leistungsperspektive
© Adis Data Information BV 2003. All rights reserved.
4. Conclusion
Because of the growing appreciation for the benefits
184 of engaging in physical activity and exercise,
people are embarking on novel exercise programmes to maintain or enhance fitness and health. However, during the early stages of a new exercise
Kennesaw, Georgia, USA
programme, muscle weakness and soreness may
Sports Med 2003; 33 (3): 177-186
occur which could compromise progress
and adher© Adis Data Information BV 2003. All rights reserved.
Sports Med 2003; 33 (3)
0112-1642/03/0003-0177/$30.00/0
The objective of this article is to examine the use of NSAIDs for attenuating
Abstract
ence to the programme. This may also be applicable
exercise-induced muscle injuries (EIMI), with an emphasis on their safety and
ata Information BV 2003. All rights
reserved.
to athletes
who must compete on successive days
usefulness
for improving muscle function and reducing soreness. NSAIDs
are
some of the most widely consumed medications in the world, and NSAID use as
regardless
of muscle soreness and weakness. Curtherapy for EIMI has increased dramatically over the last 20 years. However,
there
is a lack of agreement concerning NSAID effectiveness for this purpose. The lack
rent data suggest that therapeutic and prophylactic
of consensus about the efficacy of NSAID use in relation to EIMI has spawned a
recent interest in sports medicine research regarding NSAIDs.
use of NSAIDs may be beneficial for short-term
The application of a variety of methods used to induce, assess and quantify
muscle injury has contributed to the inconsistency among the findings recovery
regarding
of muscle function and reduced soreness
the efficacy of NSAIDs for EIMI. Therefore, future studies should focus on the
following exercise for healthy adults. Nevertheless,
evaluation of muscle injury and function, with the use of better functional
measurement tools and more uniformity in the assessment tools used. However,
is advised for at-risk individuals and for
from review of the current literature, it is concluded that NSAID usecaution
for brief
periods of time is beneficial for short-term recovery of muscle function and is an
prolonged use to avoid the risk of adverse effects.
important laboratory tool for the study of EIMI.
1. NSAIDs
wing
1.1 NSAID Mechanism of Action
NSAIDs have been available for over 100 years,
since aspirin became available in 1899.[1,2] However, their anti-inflammatory effect was not recognised
until 70 years later when Vane[3] found that aspirin
and similar agents inhibited the synthesis of prostaglandin E2 (PGE2), the primary mediator of acute
novel exercise program:
EIMI (DOMS)
oidal anti-inflammatory drugs.
1675-8
12. Farquhar WB, Morgan AL, Azm
acetaminophen and ibuprofen on
kidney. J Appl Physiol 1999; 86
13. Henry D, Page J, Whyte I, et al.
anti-inflammatory drugs and th
therapeutic
and prophylactic
renal impairment
in elderly sub
trolleduse:
study.yes
Br J Clin Pharmac
short term
14. Sandler D, Burr F, Weinberg C. No
drugs and the risk for chronic re
at-risk 1991;
individuals:
no
155: 165-72
15. Page J, Henry D. Consumption of N
of congestive heart failure in
recognized
prolonged
use:public
no health problem
777-84
16. Greene GA. Understanding NSAI
Acknowledgements
inflammation. PGE2 and prostacyclin are potent
Clin Cornerstone 2001; 3 (5): 50
peripheral vasodilators that act synergistically with
17. Mitchell JA, Akarasereenont P, Th
bradykinin and histamine in producing oedema and
The
author
thanks
Steve
Lanier,
Dr
Erica
Jackson,
Dr
ity of nonsteroidal antiinflamm
inflammatory pain.[4,5]
constitutive and inducible cycloo
Stevenson, Richard Burke and Scott Kimberly for their
Inhibition of prostaglandin synthesisScott
is proposed
U S A 1993; 90: 11693-7
as the main mechanism of action for theassistance
therapeutic in the preparation of this manuscript. No sources of
effects of NSAIDs.[5] Most NSAIDs currently avail18. Cryer B, Feldman M. Cyclooxyge
funding
able reversibly inhibit cyclo-oxygenase
(COX) bywere used to assist in the preparation of this manuselectivity of widely used no
competing with the substrate arachidonic
acid The
for author has no conflicts of interest that are directly
script.
drugs. Am J Med 1998; 104 (5):
the active site of the enzyme. Thus, the enzyme is
relevant to the content of this manuscript.
19. Slatis P, Ruusinen A. Orthopedic
land: trends in consumption of
Acta Orthop
Scand
Suppl
1991;
Univ.-Prof.
Dr. med.
Holger
Gabriel
References
20. Asmussen
E. Observations on exp
Lehrstuhl für Sportmedizin
und Gesundheitsförderung
1. Wallace J. Nonsteroidal anti-inflammatory drugs and gasFriedrich-Schiller
Jena2:
Acta RheumatolUniversität
Scand 1956;
troenteropathy: the second hundred years. Gastroenterology
21. Davies CT, White MJ. Muscle w
Carbohydrates?
M ig r ä n e -
u
SEMINAR – FORTBILDUNG
he
KG
sc
M
– Doping mit Schmerzmitteln?
)
De
ut
Geht man von den gültigen Dopingdefinitionen aus, ist die
Schmerztherapie mit NSAR und anderen Analgetika keine
Regelmäßiger Sonderteil der
unerlaubte Leistungssteigerung: Der Athlet versucht, durch
MMW-Fortschritte der Medizin,
die
Behandlung
einer
schmerzhaften Funktions- und /oder
betreut von der
Deutschen
Migräneund
Kopfschmerzgesellschaft
(DMKG)
Strukturschädigung lediglich auf sein normales Leistungsund der Deutschen
Schmerzgesellschaft
niveau
zurückzukehren.e.V.
Der Tatbestand des Doping ist aber
erst
erfüllt,
wenn
verbotene Substanzen oder Methoden anVerantwortlich:
Prof.
Dr. med.
A. Straube;
gewendet
werden,
um die Leistung über das Niveau zu steiProf. Dr. med. T. R. Tölle, beide München
gern, das mit erlaubten Mitteln erreicht werden kann.
Schmerztherapie in der Praxis
TONI GRAF-BAUMANN
Wer Schmerzen hat, kann keine sportlichen Bestleistungen abrufen. Immer
mehr Leistungs- und sogar Freizeitsportler schlucken deswegen Analgetika,
häufig schon vorbeugend. Doch selbst die Einnahme von rezeptfrei erhältSEMINAR – FORTBILDUNG
lichen
Schmerzmitteln kann bei starker körperlicher Belastung fatale Folgen
haben.
– Tabelle 1
T. Graf-Baumann / Studie der Sporthochschule Köln mit DGSS und FIFA
fs c
Kop h merz
s c h aft ( D
„Ohne Schmerzmittel läuft
nichts“
nd
s e ll
Missbrauch im Sport nimmt zu
ge
Selbstangaben zur Einnahme von
Analgetika im Mannschaftssport
– Abbildung 1
Leistungszuwachs
durch
Doping
Schmerzmittelapplikation im Wettkampf und Training
In Prozent der Fälle (mehrfache Angaben erlaubt)
60
©T. Dr.
Graf-Baumann
Nach
Hans Geyer, Sporthochschule Köln
_
rel. Häufigkeit (%)
Nicht nur ein Problem im Teamsport
wegs um krasse
Einzelfälle handelt, son-Wettkampf
Diclofenac
11%
50,4
50
Nimesulid (selektiver COX-210%
dern um einen
zunehmenden Trend,TrainingHohe Prävalenzen beim Gebrauch von
44,3
Hemmer)
Prof. Dr. Toni
NSAR und anderen Analagetika wurden
wird
ASS
6%
40 durch diverse Untersuchungen beGraf-Baumann
Normales Leistungsniveau
33,3
Paracetamol
4%
legt.30
30,0 auch in einer Studie der SporthochschuRheintalklinik,
Ketoprofen
2% Bad
26,7
le Köln zusammen mit der Deutschen
Ibuprofen
22,2
Krozingen,2%
Mitglied
Piroxicam
2%
20
Schmerzgesellschaft und der FIFA aufExzessiver Analgetikagebrauch im
der Doping-KontrollThiocolchicoside (Muscoril,
2%
Rückkehr zum normalen
Kommission DFB
Myoril, Neoflax)
gedeckt. Von 2860 Fußball-, 1222
HandProfi-Fußball
10
Leistungsniveau durch
Etoricoxib
2%
ball- und 87 Feldhockeyspielern gaben
Bei der Fußball-WM 2010 nahmen 60%
NSAID‘s
Ketorolac
2%
0
Kraftsport
Fußball
Radsport
No NSAR
68%
32% an, mindestens ein solches Medikader Spieler Schmerzmittel, davon 39%
ment eingenommen zu haben (s. Tab.
vor Doping
jedem Spiel
Dvorak
Marathon ohne
– auch(Tscholl
das solltePM,
möglich
sein.J.
aufgrund von Herzinfarkten unter ASS.
Magen-Darm-Blutungen, Nierenversasiotherapeuten, Trainer, Betreuer
1). und
Auch Einzelsportarten sind von dem
Br J Sports Med 2011). Aber nicht nur
„Es tut alles weh, aber man hat keine
Interessanterweise standen die Gesundgen und Infarkte bei Marathonläufern
Funktionäre; rechtliche Konsequenzen
beinurmännlichen
Profi-Fußballern,
auch ggf. mit beZeit
Schmerzen
nachzudenken.
heitsstörungen
unwesentlich mit
Es über
gibt indie
der Literatur
zahlreiche
Hinwegen Körperverletzung,
dem
Alter,
der
Marathonerfahrung
oder
auf die gravierenden
Nebenwirrufs-Dr.
und sportrechtlichen
bei Frauen
Jugendlichen,
die
an in- KonsequenVorweise
großen
Wettkämpfen
oderProblem
ohne betroffen,
und Trainer können sich schuldig und
Überlastung
der Muskulatur ohne auswieund
Daten
von
dem Trainingszustand in Zusammenkungen und Risiken einer nicht ausreizen, sind nicht auszuschließen.
teilweise haftbar machen, wenn sie eine
reichende
Regenerationsintervalle zu
Fußballturnieren
teilnehHans
Geyerternationalen
vom Doping-Kontroll-Laausreichende
Erholungszeiten
ichDagegen
hang.
bestand
eine klare Beziechend indizierten,
nicht überwachtenmuss
In der o.g. Studie
der Sporthochschunicht indizierte, falsche oder unzureivermeiden.
In den allermeisten Fällen
bor
der
Sporthochschule
Köln zeigen:
hung
zur eingenommenen
Schmerzmitund/oder nicht adäquat
dosierten
Be- bin
levon
Köln Schmerzmitwar auffällig,
dass die Kenntnis
men, ist die
Einnahme
Schmerzmittel
nehmen,
sonst
ich
teldosis.
Bereits
die
im
rezeptfreien
Verhandlung mit NSAR und anderen Anal- Bei
möglicher
Gesundheitsschäden
keinen
chende Schmerzbehandlung akzeptieerfolgt
die langfristige Einnahme ohne
Wettkämpfen
im verbreitet.
Kraftsport
undsechs
im FIFA-Turteln weit
Bei
bald raus aus dem Geschäft“ (Bettina
Schmerztag
2014
kauf erlaubten Dosen führten zu Gegetika. Die Medikamente können die
Einfluss auf den Konsum von SchmerzUniv.-Prof. Dr. med. Holger Gabriel
ren. Das bezieht auch die Entscheidung
Blutwertkontrollen.
standen
50% bzw.
27%
der
nieren waren
NSAR
die
am Spezialist:
häufigsten
Uhlig,
Siegerin
desundBlack-Forest-Ultrasundheitsstörungen.
Blutgefäße
schädigen
zu Darmblu- Radsport
mitteln
Das
zeigt, dass rein ratioLehrstuhl für Sportmedizin und Gesundheitsförderung
Hausarzt
undhatte.
Diese Ergebnisse
weisen darauf hin,
tungen und Nierenversagen
Herangehensweisen
in
der Prävenein, wann ein Friedrich-Schiller
Athlet ins Training
bzw. inJena
Die
für
eine leitliniengerechte
Athleten
unter
Schmerzmitteln
(s.nale
Abb.
verschriebenen
Medikamente;
wurBike-Marathon
2012).führen.
„Viel wichtiger
Universität
Gemeinsam
gegensie
den
Schmerz
dass im Prinzip harmlose Schmerzmittel
Diesen Risiken setzen sich nicht nur
tion von Schmerzmittelmissbrauch im
den Wettkampf zurückkehren darf.
Schmerztherapie
nötigen diagnostischen
1). Zu den den
am häufigsten
in den 72verwendeten
Stunden vor dem
Spiel
als Kinesiotape ist natürlich Voltaren.
© Maridav / fotolia.com
Medizin- und Gesundheitsperspektive
SEMINAR
5. Mitteldeutscher
„Eulen nach Athen tragen“
Embolia cutis medicamentosa
NICOLAU SYNDROME
NICOLAU SYNDROME
861
861
• Analgetika sind effektive Wirkstoffe.
• Analgetika haben häufige und seltene erwünschte und unerwünschte Wirkungen.
• Manche Wirkungen sind allgemein bekannt (Experten- und Laienwissen).
Acta Orthop. Belg., 2008, 74, 860-864
Fig. 1. — Photograph of right gluteal region on day 10 post
• Manche Wirkungen sind nur Ärztinnen isinjection
illustrating the nature and extent of the rash. Top left
a small eschar not related to the actual injection site, which
of painprior
immediately
on insertion
of the
needle
continuedlevel
to enlarge
to eventually
sloughing
(Line
=
und Ärzten bekannt (Expertenwissen). 2.5
cm). and his coach observed more bleeding than he felt
was usual. On arrival, ice was applied to the area
and intravenous morphine was required to settle his
• Manche Wirkungen erkennen nur level of pain.
pain immediately on insertion of the needle
Nicolau
syndrome
in
anrevealed
athlete
following
Immediate
assessment
a blanching,
purand his coach
observed
more
bleeding
than
he felt
einschlägig erfahrene Ärztinnen puric
rash
which
evolved
rapidly
(over
hours)
to a
intra-muscular
injection
was
usual. On arrival, diclofenac
ice was applied
to the area
mottled appearance (fig 1). The athlete felt this may
and intravenous
morphine was required to settle his
have been the result of placing ice on the area
und Ärzte (Expertenerfahrung).
pain.
Fig. 1. — Photograph of right gluteal region on day 10 post
injection illustrating the nature and extent of the rash. Top left
is a small eschar not related to the actual injection site, which
continued to enlarge prior to eventually sloughing (Line =
2.5 cm).
a
a
CASE REPORT
b
b
immediately after the event. The area around the
Bruce HAMILTON
, Peter
FOWLER, Howard
GALLOWAY
, Nebojsa
POPOVIC
Immediate
assessment
revealed
a tender
blanching,
purinjection
site was exquisitely
to palpation
CASE REPORT
Acta Orthop.
Belg.,
74, 860-864
puric rash
(over
hours)hiptojoint
a
andwhich
he2008,
had evolved
pain
withrapidly
any passive
or active
c
movement.
Initial
differential
diagnosis
included
a
mottled
appearance
(fig
1).
The
athlete
felt
this
may
From Aspetar, Qatar Orthopaedic and Sports Medicine Hospital, Doha, Qatar
localthe
toxicresult
reaction
the Dicolofenac,
bleedhave been
of toplacing
ice on acute
the area
Fig. 2. — a) Inversion recovery axial MR images performed
ing
and
acute
compartment
syndrome.
He
was
startimmediately after the event. The area around the
24 hours after injection show extensive oedema in the subcutaed on oral prednisolone and was admitted for IV
neous fat extending to the midline posteriorly. There is also
injectionanalgesia.
site was exquisitely tender to palpation
extensive oedema throughout the superior aspect of the gluteus
and he
painlittle
with
any passive
or active hipoccurred
joint
and the medialused
aspect of the gluteus medius associatNicolau Syndrome (also known
ashad
Embolia
cutis
Intra-muscular
Diclofenac maximus
is a commonly
Very
symptomatic
improvement
ed cwith inter-muscular fluid. The needle track can be seen as a
medicamentosa and livedo-like
dermatitis)
is
a
rare
movement.
Initial
differential
diagnosis
included
a
medication
within the first 24 hours,anti-imflammatory
and the gluteus maximus
straightin
highprofessional
signal line extending to the deep aspect of the
Nicolau
in
an
athlete
following
but severe localized adverse drug
to a range
localreaction
toxic
tosyndrome
the Dicolofenac,
acute
bleedandreaction
medius
became
increasingly
tense
and
painful
gluteus
maximus.
T1 weighted images showed no evidence
sport, but to our knowledge, no cases of The
Nicolau
Fig.
2. —
a) Inversion recovery axial MR images performed
of
acute
haemorrhage.
of intra-muscular preparations.
It
manifests
as
acute
intra-muscular
diclofenac
injection
to
palpation.
The
MRI
findings
24
hours
post
injecing and acute compartment syndrome.
wasbeen
start-presented
SyndromeHehave
in the
sports
mediDr.was
med.
Holger
Gabriel
24
after
injection
show extensive
oedema
in
subcutab) hours
A follow-up
post Univ.-Prof.
gadolinium
scan
performed
at 7the
days
pain, cutaneous, subcutaneous
and
intra-muscular
tion
can be seen in and
fig 2.
Haematological
and
bioed
on
oral
prednisolone
was
admitted
for
IV
tothe
lookfat
for
evidence
of to
focal
A fat suppressed
cine literature. We describe
syndrome
intheamuscle
neous
extending
midline
posteriorly.
There is also
Lehrstuhl
für
Sportmedizin
und necrosis.
Gesundheitsförderung
Hausarzt
und
Spezialist:
inflammation and necrosis immediately
following
an revealed an elevated Creatine
chemical
testing
T1 image oedema
shows two
small areasthe
of necrosis
the medial
glu-gluteus
throughout
superiorinUniversität
aspect
of the
analgesia.
21-year-old
national
level extensive
race
walking
athlete
Friedrich-Schiller
Jena
Gemeinsam
gegen
den
Schmerz
teus
medius.
There
is
low
grade
enhancement
of
the
residual
Bruce
HAMILTON
, Peter Fas
OWLER
Howard
GALLOWAY
P
OPOVIC
kinase
and
myoglobin
well, as
other markers
of, Nebojsa
injection, with potentially
devastating
sequelae.
We
maximus and the medial aspect of the gluteus medius associatVery little symptomatic improvement
occurred
following
an
intramuscular
(IM)
injection
of
muscle
oedema.
muscle
damage
ed with inter-muscular fluid. The needle track can be seen as a
describe the syndrome in a 21-year-old
national
level(fig 3). White cell count, inflamma-
5. Mitteldeutscher
Schmerztag 2014
es?
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Gesundheitsgefährdendes Verhalten zu eigenen Lasten und zu Lasten Dritter
5. Mitteldeutscher
Schmerztag 2014
Wie entsteht eine „Analgetika-Hausapotheke“?
„Ich kann vor lauter Reizhusten nicht schlafen.“
„Ich habe solche Kopfschmerzen.“
„Mir tut der Rücken weh.“
„Mir tut der Rücken immer noch weh.“
lle
o
k
o
rot nem
p
tnis Selte
h
c
dä und )
e
e G figem 1989
n
e
t
Eig Häu (sei
von
„Ich habe eine Zerrung.“
Paracodin
Freund
Gelonida
Eltern
Voltaren
Ibuprofen
Voltaren-Gel
„Heute ist das Lokderby.“ (Fußball)
Ibuprofen + i.a. Injektion
„Ich habe meine Tage.“
Buscopan
„Ich habe Halsschmerzen.“
Lokalanästhetikum (topisch)
„Ich bin dann immer so aufgeregt, fast panisch!“
Adumbran
„Ich habe erst einen Wettkampf in Asien, dann Neuseeland.“
„Beim Werfen tut mir jedes Mal der Ellenbogen so weh.“
Baldriparan, Planum
Diclofenac
Sportkamerad
Physiotherapeut
selbst
Mitspieler, Sportarzt
Freundin
selbst
„gefunden“
Hausapotheke
Arzt
„Oma doch Tropfen gegen ihre Schmerzen bekommen.“
„Außerdem hat sie (Red.: Der Opa) noch ein Pflaster bekommen. Da sagt sie immer: Das ist wirklich Doping!“ (lacht)
Tramadol Tropfen
Oma (unfreiwillig)
Opioid-Pflaster
Opa (unfreiwillig)
„Beim Übertrainings-Syndrom helfen doch Antidepressiva, oder?“
Venlafaxin
nur 3 Tage, Familie
„Wenn Du die Pille nimmst, kommst Du besser durch!“
unbekannt
Sportkamerad
Webpage verspricht: „No pain, more gain!“
Im Night-Club: „Komm, lass Dich gehen.“
Auf der Piste: „Kleiner Feigling.“
Après Ski: „Alles Crystal-klar bei Dir?“
Anabole Steroide, Kreatin, Arsen, Lack
Amphetamin
Alkohol + ?
Metamphetamin + ?
Internet
Night-Club, Toilette
Bar, unter der Theke
Parkplatz
? Gesundheitsgefährdendes Verhalten zu eigenen Lasten und zu Lasten Dritter
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Hausapotheke (eigene, fremde), „Over the counter“, „Buy by click“
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5. Mitteldeutscher
Schmerztag 2014
Affiliations
2
Exercise Science, University of South Carolina, Columbia, United States
Pathology, Microbiology & Immunology, School of Medicine, University of South Carolina, Columbia, United States
Abstract
Key words
▶ NSAIDs
●
▶ mortality
●
▶ exercise performance
●
▼
We examined the possible negative interaction
of the combined use of the NSAID indomethacin
(IND) and exercise in mice. Mice were assigned
to one of 4 groups: Exercise 2.5 mg/kg IND (Ex2.5), Sedentary 2.5 mg/kg IND (Sed-2.5), Exercise
5.0 mg/kg IND (Ex-5.0) and Sedentary 5.0 mg/
kg IND (Sed-5.0). Mice were given IND (gavage)
1101 h prior to exercise (treadmill run at 30 m/min,
8 % grade for 90 min) or rest for 14 consecutive
100days. Run times, body weight and mortality were
recorded daily. Sed-5.0 was highly toxic and
90caused 70 % mortality compared to Sed-2.5, which
was well tolerated (0 % mortality) (P < 0.05). While
the addition of exercise had no greater effect on
mortality in Ex-5.0, it increased it in the 2.5 group
(52 % vs. 0 %; P < 0.05). Run time was reduced from
baseline beginning on day 2 (Ex-5.0), or day 3
(Ex-2.5) (P < 0.05). Body weight (recorded in the
2.5 mg/kg groups only) was decreased from baseline in Ex-2.5 and Sed-2.5 (P < 0.05), but this effect
occurred earlier and was of greater magnitude in
Ex-2.5. Exercise combined with IND use can lead
to serious side effects in mice. Future research is
needed to test the hypothesis that this effect is
due to increased GI permeability and whether
humans are also at risk.
äu
se
!
Körperliches Training + Indometacin
Überlebensrate
M
estinal damage, and peptic
en combined with exercise
e exercise bouts at doses of
g dose was selected on the
ed IND dosage for humans
e as it is not uncommon for
han the prescribed amount
accepted after revision
July 30, 2012
AID at a time [22, 23].
80
*
Introduction
re purchased from Harlan
to our facility for at least 3
Mice were housed, 4–5 per
h light-dark cycle in a low
idity, low noise) and given
itum. The Institutional Anie University of South Caroresearch performed in this
the International Journal of
Percent Survival
this condition may be exacerbated [11, 18]. For
example, it has been shown that GI permeability
It is well known that exercise can trigger an
is increased if aspirin or ibuprofen is used prior
infl
ammatory
response,
the
magnitude
of
which
to prolonged exercise [11]. Further, Nieman et al.
60
is dependent on the mode, intensity, duration
reported an elevation in inflammatory cytokines
and
novelty
of
exercise
[
5
,
18
]
.
For
example,
in ibuprofen users compared to non-users fol50
eccentric exercise can result in a much larger
lowing a 160-km race [18]. The use of NSAIDs in
Bibliography
increase
in
infl
ammatory
cytokines
compared
to
combination with exercise may lead to detri40
DOI http://dx.doi.org/
uphill running [3, 5]. It has also been reported
mental conditions resulting from endotoxic
10.1055/s-0032-1323718
30that exercise of long duration can result in large shock and systemic inflammatory response synPublished online:
September 12, 2012
increases in plasma inflammatory cytokines
drome (SIRS). However, to our knowledge there
Int J Sports Med 2013; 34:
20[17, 18]. Such exercise-induced inflammation has are no controlled experimental studies that have
191–195 © Georg Thieme
been associated with muscle soreness and pain
tested this hypothesis.
Verlag KG Stuttgart · New York
10that can lead to deficits in performance [3–5, 17]. The purpose of this study was to investigate posISSN 0172-4622
As a result, non-steroidal anti-inflammatory
sible serious side effects associated with the
0drug (NSAID) use is widespread among athletes combined use of the prescription NSAID,
Correspondence
and
mice.15
The
0military
1 personnel
2
3 [7]. 4
5
6
7 indomethacin
8
9 10(IND),
11 and12exercise
13 in14
Dr. E. Angela Murphy
Although
commonly
used,
NSAIDs
have
been
exercise
protocol
was
designed
to
mimic
exercise
Pathology, Microbiology &
Day
Immunology
associated with adverse side effects including
training similar to that of long-distance runners,
School of Medicine
mucosal damage in the
gastrointestinal
Sed
2.5
Sed(GI)
5.0 professional
Ex 2.5athletesExand
5.0warfighters. IND was
University of South Carolina
tract; alterations in mucous secretion can result
used as it is one of the most commonly pre6439 Garners Ferry Rd.
in increased levels of non-mediated diffusion of
scribed non-selective NSAIDs. This class of
29209 Columbia
large
molecules,
including
bacteria
from
the
NSAIDs has been linked with serious side effects
United States
lumen
to
the
blood
causing
endotoxemia
and
given their ability to inhibit the activity of
Tel.: + 1/803/216-3414
inflammation [20]. Moreover, when NSAID use is
cyclooxygenase (COX) -1 in addition to COX 2;
Fax: + 1/803/216-3413
[email protected]
combined with exercise there is evidence that
COX-1 inhibition is associated with GI complica-
70▼
*
*
Fig. 1 Effect of IND and exercise on mortality in mice. Mice were given
either 2.5 mg/kg or 5.0 mg/kg IND daily and 1 h prior to exercise for
14 consecutive days. Mortality was recorded daily (n = 9–21/group).
*P < 0.05.
Enos RT et al. Negative Interaction between Indomethacin … Int J Sports Med 2013; 34: 191–195
ratory shows no decrease
in run time or alteration in body
5. Mitteldeutscher
2014 protocol.
weight in mice in responseSchmerztag
to this same exercise
Body weight and mortality
Kein Training + 2.5 mg/kg
Training + 2.5 mg/kg
Training + 5.0 mg/kg
Kein Training + 5.0 mg/kg
nd Landesbibliothek Jena. Copyrighted material.
R. T. Enos , J. M. Davis , J. L. McClellan , J. L. Lake , M. D. Carmichael , E. A. Murphy
1
Downloaded by: IP-Proxy CONSORTIUM:DFG (TULB Jena), Thüringer Universitäts- und Landesbibliothek Jena. Copyrighted
Authors
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5. Mitteldeutscher
Schmerztag 2014
cantly higher (0.87±0.09 per match/per player vs
0.77±0.03, p<0.01). This was driven by a higher use
of NSAIDs (0.46±0.05 vs 0.36±0.02; p<0.01) and
Downloaded from http://bjsm.bmj.com/ on November 14, 2014 - Published by group.bmj.com
d as in more injections of corticosteroids and local anaesWorld thetics (0.06±0.01 vs 0.03±0.01; p<0.01) When
we of
examined
regional
patterns,
the continents
medi-Abuse
medication
during
international
football
of North and South America had significantly
edingcompetition
in 2010 – lesson not learned
sician. the highest reported use of medication per match
ch
c,
hur,
ale de
rich,
l,
ic,
2011
12
1,2 Jiri Dvorak1,3
Philippe Matthias Tscholl,Downloaded
from http://bjsm.bmj.com/ on November 14, 2014 - Published by group.bmj.com
Br
J Sports Med 2012;46:1140–1141. doi:10.1136/bjsports-2011-090806
The substance-groups were as follows: NSAIDs,
ABSTRACT
Short reports
Background The use of medication in professional football analgesics, injected corticosteroids and local
anaesthetics, muscle relaxants, respiratory drugs,
has previously been shown to defy clinical guidelines.
for gastrointestinal
and antimicrobial
Table
1 and
A comparison
of FIFAofWorld
Cupwho
2002, medication
2006 and 2010
– the use of medication
per match and per tournament.
Materials
methods Physicians
the teams
purposes and others.
participated at the 2010
FIFA World Cup provided the
2010
2006*
2002*
7/13/2012 7:57:30 PM
list of medications used by each player within the 72 h
No of players
No of players
Participating players
preceding every match.No of players
Per match71.7% of all players
During tournament
Per matchtook part in this
During
tournament
Per match
Thirty-two countries
tournaResults During the tournament
nominated 23
each (736 (%)
took medication, and 60.3%
(444 of 736
(n=2944)
(%)players) took
(n=736) ment,
(%) which (n=2944)
(%)players (n=736)
(n=2944)
(%)
players in the tournament) and participated in 64
painkilling agents at least once. Over a third of players
Any
medication
1418
71.7%(29441257
42.7%
508
69.0%
1335
45.3%
matches
player matches).
(39.0%)
took a painkilling
agent before48.2%
every game.528
NSAIDs
34.6%
54.8%
855
29.0%
399
54.2%
960
32.6%
More
medications were1020
used during the
finals than403
during
the qualifying round
Injections*
96of matches (pool
3.3% games)54
103
3.5%
58
7.9%
120
4.1%
Data 7.3%
presentation
2
3
(0.87±0.09
The14.8%
results were
follows:83 (1) sub- 11.3%
Analgesicsvs 0.77±0.03,
189p<0.01). Players
6.4%from North
109
108calculated as
3.7%
131
4.4%
and South America took almost twice the number of
stance/player
(mean
β-2 agonists
58
2.0%
20
2.7%
31 intake per
1.1%player per
12 match 1.6%
34
1.2%
medications than did players from other continents
or per tournament) and (2) number of individual
Antihistamines
42
5.7%
106
3.6%
55
7.5%
60
2.0%
(1.18±0.08
vs 0.64±0.03;64p<0.01). 2.2%
player reported to be using a substance (per match
Any
supplement
34.6% by the
353
48.0%
1041
35.4%
317
43.1%
925
31.4%
Conclusion
The use of1019
medication reported
or per
tournament).
team physicians in international football competition
*Corticosteroid
and localuse
anaesthetic
injections
only.3
is increasing. Systematic
– medication
for every
Data presentation
NSAID,
non-steroidal
anti-infl
ammatory
drugs.
match – appeared to be the norm in certain teams. This
The statistical methods applied were frequencies
has implications for player health. These data encourage and cross-tabulations. Significance was considefforts to better understand, and to address, this
ered at p≤0.05.
continuation in professional athletes, and to
and
per player (1.18±0.08 and 0.64±0.03, respectively;
p<0.01).
potential disastrous practice in professional sports.
During tournament
(n=736)
(%)
500
403
77
91
8
43
314
67.9%
54.8%
10.5%
12.4%
1.1%
5.8%
42.7%
start respecting
biology when administering medication.
Differences in prescription practice varied enormously among
RESULTS
countries. The range of medication reportedOn
was
from players
0.22 totook 0.8 medical substances
average,
5.
Mitteldeutscher
Contributors Every author contributed substantially to this publication.
3.13 per player per game; NSAID prescription
ranged
nearly
before each match.
More
than
two-thirds
of all medSchmerztag
2014
Acknowledgements
(Fédération
INTRODUCTION
Univ.-Prof.
Dr. med. Holger Gabriel
20-fold
– from 0.06 to 1.17 NSAIDs per player
and
per
match.
ication were in the following drug class: oral anal-The authors gratefully acknowledge FIFA
Previous reports have documented the use of medication in International Football for male, female
1–4
5–7
Lehrstuhlthis
fürstudy.
Sportmedizin
und Gesundheitsförderung
Hausarzt
Spezialist:
Internationale
de Football Association) for funding
The authors
express
gesics (NSAIDs:
49.0%und
(n=1144),
other analgesics:
Friedrich-Schiller
Universität Jena
Gemeinsam gegen
den
Schmerz
our gratitude injections,
to the members of the FIFA Sports Medical Committee (Chairman:
10.5% (n=246): 2.3% local anaesthetic
lowthenumber
of physicians participating at a FIFA World Cup
pare the
qualification rounds (32 teams), the rate of
l in 2010
compared
a single
event.
medicationwith
per match
and per sports
player was
signifi- However, the differences
cantly higher (0.87±0.09 per match/per player vs
between
the countries were significant and striking. Whereas
November
14,
- Published
by group.bmj.com
most
of 2014
the(0.46±0.05
team
physicians
did not
of NSAIDs
vs 0.36±0.02;
p<0.01)
and perform injections with
more injections of corticosteroids
and 32),
local anaessed as in
glucocorticosteroids
(23 of
in one team, three to four
orts
Short reports
thetics
(0.06±0.01
vs
0.03±0.01;
p<0.01)
When
A World
players
had peritendinous
or continents
intra-articular injections before
we of
examined
regional
patterns,
the
ed mediAbuse
medication
during
international
football
of game
North and
South
America had significantly Also, the use of NSAIDs
receding
each
with
glucocorticosteroids.
competition in 2010 – lesson not learned
hysician. the highest reported use of medication per match
seems
to Tscholl,
be per
strongly
depended
on the team physician.
1,2
1,3
use of
medication
match
and per tournament.
Philippe
Matthias
Jiri Dvorak
edical
Research
sclinic,
d
ent,
Winterthur,
erland
nationale de
on, Zurich,
Downloaded from http://bjsm.bmj.com/ on November 14, 2014 - Published by group.bmj.com
Br
J Sports Med 2012;46:1140–1141. doi:10.1136/bjsports-2011-090806
The substance-groups were as follows: NSAIDs,
ABSTRACT
Background The use of medication in professional football
has previously been shown to defy clinical guidelines.
Materials and methods Physicians of the teams who
participated at the 2010 FIFA World Cup provided the
list of medications used by each player within the 72 h
preceding every match.
Results During the tournament 71.7% of all players
took medication, and 60.3% (444 of 736 players) took
painkilling agents at least once. Over a third of players
(39.0%) took a painkilling agent before every game.
More medications were used during the finals than
during the qualifying round of matches (pool games)
(0.87±0.09 vs 0.77±0.03, p<0.01). Players from North
and South America took almost twice the number of
medications than did players from other continents
(1.18±0.08 vs 0.64±0.03; p<0.01).
Conclusion The use of medication reported by the
team physicians in international football competition
is increasing. Systematic use – medication for every
match – appeared to be the norm in certain teams. This
has implications for player health. These data encourage
efforts to better understand, and to address, this
potential disastrous practice in professional sports.
ayers CONCLUSION
ch
4)to
Tscholl,
ssclinic,
8008,
d;
e.ch
mber 2011
ary 2012
st
.
g
o
y
2002*
analgesics, injected corticosteroids and local
anaesthetics, muscle relaxants, respiratory drugs,
medication for gastrointestinal and antimicrobial
purposes and others.
No of players
2006;16:27–33.
8. Thuyne WV, Delbeke FT. Declared use of med
2008;18:143–7.
9. Tscholl P, Alonso JM, Dollé G, et al. The use o
in top-level track and field athletes. Am J Spor
10. Alaranta A, Alaranta H, Heliövaara M, et al. A
medications in Finnish elite athletes. Int J Spor
11. Tscholl P, Alonso JM, Junge A, et al. Risk Fac
Elite Athletes. Oslo: ECSS 2009.
12. Paoloni JA, Milne C, Orchard J, et al. Non-stero
medicine: guidelines for practical but sensible use
13. Warden SJ. Prophylactic misuse and recomm
inflammatory drugs by athletes. Br J Sports M
14. Vuolteenaho K, Moilanen T, Moilanen E. Non
cyclooxygenase-2 and the bone healing proces
NSAID2008;102:10–14.
15. Wheeler P, Batt ME. Do non-steroidal anti-infl
stress fracture
healing? A short review. Br J Sp
intraarticular
corticosterioid
16. Virchenko O, Skoglund B, Aspenberg P. Parec
injection
before match
improves later remodeling. Am J Sports Med 2
17
Porucznik CA, Reeser JC, Willick S, et al. Use
collegiate club volleyball players. Med Sci Spo
18. Mikkelsen UR, Langberg H, Helmark IC, et al.
satellite cell proliferation in human skeletal mu
not conform
to2009;107:1600–11.
guidelines
J Appl Physiol
19. Anderson SD, Sue-Chu M, Perry CP, et al. Bro
applying to inhale a beta2-agonist at the 2004
Immunol
2006;117:767–73.
Problem:
Wish
to stay at highest
7/13/2012
The use During
of medication
reported
by 7:57:30
the PMteamDuring
physicians
in
Participating players
tournament
Per match
tournament
international football competition is high, and still seems to be
(%)
(n=736)
(%)
(n=2944)
(%)
(n=736)
(%)
increasing. The major problems are NSAIDs. Systematic use of
42.7%
508
1335
67.9%
presentation
NSAIDs
was
found 69.0%
in Data
a few
teams. Also,45.3%
regular500
administration
29.0%
399
54.2%
960
54.8%
of
intra-articular
corticosteroid
injections32.6%
before a403
match needs
to
58
7.9%
120
77
be3.5%
questioned
and further
investigated.
It 4.1%
is unclear
whether10.5%
this
3.7%
83
11.3%
131
4.4%
91
12.4%
Data presentation
intake might also be partially
due to a ritual by the players.
1.1%
12
1.6%
34
1.2%
8
1.1%
These timely data suggest that medications are widely
3.6%
55
7.5%
60
2.0%
43
5.8%
RESULTS
prescribed in elite sport
and this may not be consistent with
35.4%
317
43.1%
925
31.4%
314
42.7%
INTRODUCTION
guideline
advice or even biological plausibility. Given that elite
players and physicians working at the elite level are role models, it is clearly time to seek alternative management methods.
There is a need for better and safer methods for performance
continuation in professional athletes, and to start respecting possible level of performance
Br
J Sports when
Med 2012;46:1140–1141.
biology
administeringdoi:10.1136/bjsports-2011-090806
medication.
Previous reports have documented the use of medication in International Football for male, female
and youth players,1–4 for Olympic Games5–7 and
other sports events.8–10 The key determinants
associated with the use of a larger number of medications in team and individual sports events were
geographical origin and certain team physicians.11
There was only small correlation with age, and no
correlation with team-success, previous or current
reported injury on the F-MARC (FIFA Medical
Assessment and Research Center) injury form
and minutes played during the tournament.2 9 11
On several occasions, preventive measures were
undertaken from the official medical board of FIFA,
where team physicians were informed and alerted
to the high use of non-steroidal anti-inflammatory
drugs (NSAIDs). Guidelines exist to guide sportsphysicians prescribing behaviour.12 13
The main goal of this study was to compare the
use of medication in international football in 2010
with previous competitions.
Thirty-two countries took part in this tournament, which nominated 23 players each (736
players in the tournament) and participated in 64
matches (2944 player matches).
The results were calculated as follows:2 3 (1) substance/player (mean intake per player per match
or per tournament) and (2) number of individual
player reported to be using a substance (per match
or per tournament).
The statistical methods applied were frequencies
and cross-tabulations. Significance was considered at p≤0.05.
On average, players took 0.8 medical substances
before each match. More than two-thirds of all medication were in the following drug class: oral analgesics (NSAIDs: 49.0% (n=1144), other analgesics:
10.5% (n=246): 2.3% local anaesthetic injections,
n=53), muscle relaxants: 3.8% (n=88)); 84.3% of all
NSAIDs were cyclo-oxygenase (COX)-I-inhibitors
and 15.6% were COX-II-inhibitors. Corticosteroid
injections were given to 2.4% of players (n=55).
Nearly half of all players (48.2%), regardless
whether they participated in the match, took some
sort of medication and to more than one-third
(34.6%) of the players at least one NSAID was
prescribed before a match. Thirty-two intra-articular, 20 intra-muscular, wherefrom five lumbar
and three peritendinous glucocorticoid injections
were reported in 25 different players, administered
within the 72 h preceding the match; 7.2% of players took at least one antibiotic at some stage during
the tournament.
Comparing the fi nal rounds (16 teams) with
the qualification rounds (32 teams), the rate of
medication per match and per player was significantly higher (0.87±0.09 per match/per player vs
of NSAIDs (0.46±0.05 vs 0.36±0.02; p<0.01) and
more injections of corticosteroids and local anaes-
Contributors Every author contributed substantially5.
to this
publication.
Mitteldeutscher
Schmerztag
2014
The authors gratefully acknowledge
FIFA (Fédération
Hausarzt
undauthors
Spezialist:express
Internationale de Football Association) for funding this study.
The
METHODS
our
gratitude
thewasmembers
of the FIFA Sports Medical Committee (Chairman:
Identical
methodological to
approach
used as in
Acknowledgements
rts-2011-090806.indd
Sec1:2
cardiovascular, gastrointestinal and renal
problems: a cohort study
http://bmjopen.bmj.com
aspirin ingestion) and two cardiac infarctions (postuse. Serious events requiring hospital admittance
aspirin ingestion). None of the control reported hospital
were reported only in the analgesics group.
admittance.
These findings pinpoint the unexpected risk of
the prophylactic use of these drugs in sports.
Conclusions: The use of analgesics before participating
1
2
2
▪ InOppel,
our study,
theNiederweis,
role of confounders,
as2 preDownloaded from http://bmjopen.bmj.com/ on
2014 - may
Published
byKüster,
group.bmj.com
in November
endurance14,sports
cause
many
potentially
Michael
Bertold serious,
Renner,2 Pascal
Ursula
Kay Brune
existing joint pain, could not be excluded.
unwanted AEs that increase with increasing analgesic
1
Open Access
Research
Pain Management Center
dose. Analgesic use before endurance sports appears to
DGS, Bonn, Bad-Godesberg,
pose
anM,unrecognised
medical problem as yet. If verifiable
To cite:
Küster
Renner B,
ABSTRACT
ARTICLE SUMMARY
Germany
OppelinP,other
et al. Consumption
that physical
activity does not automatically
endurance sports,
it requires
the attention
of their
To prevent
pain inhibiting
Objectives:
2
Department of Experimental of analgesics before a
performance,
many athletes ingest over-the-counter
Article
focushealth, but could exacerbate
physicians
and regulatory
authorities.
result in
better
marathon
and the incidence
of
Consumption of analgesics before a
and Clinical Pharmacology
(OTC) analgesics before competing. We aimed at
▪ Participation
in endurance
sports, asThis
in a maramay be
cardiovascular
(CV)
disease.
marathon
and the incidence
of
and Toxicology, FAU
defining the use
of analgesics and the relation between
thon, is growing worldwide.
OTC analgesic use/dose and adverse events (AEs)related ▪ to
the
inhibition
cyclooxygenases
Erlangen-Nuremberg,
Many
amateurs
engage in of
occasional
endurance
during
and
after
the
race,
a
relation
that
has
not
been
activities withoutanti-inflammatory
adequate training, medicaldrugs
Erlangen, Germany
cardiovascular,
gastrointestinal
and renal by non-steroidal
investigated to date.
information and experience.
(NSAIDs),
including
‘over-the-counter’
Design: Prospective (non-interventional) cohort study,
▪ They try to overcome pain during and after
Correspondence
to
problems:
a cohort
study
using an online questionnaire.
(OTC) analgesics,
that are
known to(OTC)
exacerINTRODUCTION
sports by taking
over-the-counter
Professor Kay Brune;
1 2
cardiovascular, gastrointestinal
and renal problems: a cohort
study. BMJ Open 2013;3:
e002090. doi:10.1136/
bmjopen-2012-002090
▸ Prepublication history and
Setting:
Bonn marathon
2010.
additional material for thissports
are The
becoming
increasingly
bate
kay.brune@pharmakologie. paperEndurance
are available online. To
Participants: 3913 of 7048 participants in the Bonn
med.uni-erlangen.de
However,
recent
view popular.
these files
visit
2 please
2
2 shown
2some
marathon
2010research
returned theirhas
questionnaires.
Michael Küster,1 Bertold the
Renner,
Pascal
Oppel,
Ursula
Niederweis,
Kay
Brune
journal online
Primary and secondary outcomes: Intensity of
(http://dx.doi.org/10.1136/
analgesic consumption
before sports; incidence of AEs in
Küster M, Renner B, Oppel P, bmjopen-2012-002090).
et al. BMJ Open 2013;3:e002090.
doi:10.1136/bmjopen-2012-002090
To cite: Küster M, Renner B,
Oppel P, et al. Consumption
of analgesics before a
marathon and the incidence of
e002090. doi:10.1136/
bmjopen-2012-002090
additional material for this
paper are available online. To
view these files please visit
the journal online
bmjopen-2012-002090).
MK and BR contributed
equally.
Received 12 September 2012
Revised 30 December 2012
Accepted 9 January 2013
This final article is available
for use under the terms of
the cohort of analgesic users as compared to non-users.
Results:
There was no significant difference between the
ABSTRACT
ARTICLE
SUMMARY
premature race withdrawal rate in the analgesics cohort
Objectives: To prevent pain inhibiting their
MK
and
BR
contributed
and the cohort who did not take analgesics (‘controls’).
performance, many athletes ingest over-the-counter
Article focus
equally.
However, race withdrawal because of gastrointestinal AEs
▪ Participation in endurance sports, as in a marasignificantly more frequent in the analgesics cohort
defining the use of analgesics andReceived
the relation
between2012 was
12 September
than
in the control. Conversely, withdrawal because of
OTC analgesic use/dose and adverse
events
(AEs) 2012 ▪ Many
Revised
30 December
amateurs engage in occasional endurance
muscle cramps was rare, but it was significantly more
during and after the race, a relation
that has
not been
Accepted
9 January
2013
activities without adequate training, medical
frequent in controls. The analgesics cohort had an almost
times higher incidence of AEs (overall risk difference of
This final article
available ▪ 5They
Design: Prospective (non-interventional)
cohortisstudy,
try to overcome pain during and after
13%).
This incidence increased significantly with
using an online questionnaire. for use under the terms of
sports by taking over-the-counter (OTC)
increasing analgesic dose. Nine respondents reported
the Creative Commons
Setting: The Bonn marathon 2010.
analgesics.
Attribution Non-Commercial
temporary hospital admittance: three for temporary kidney
Participants: 3913 of 7048 participants
in the
2.0 Licence;
see Bonn
failure
(post-ibuprofen ingestion), four with bleeds (postKey
message
marathon 2010 returned their questionnaires.
ingestion) andthat
two cardiac
infarctions
▪ aspirin
We hypothesised
the drugs
taken (postbefore
aspirin
ingestion).
None
of
the
control
reported
hospital
sports may increase the incidence of cardiovasanalgesic consumption before sports; incidence of AEs in
admittance.
cular, gastrointestinal and kidney damage
Conclusions:
The use
analgesics
participating
without lowering
the ofpain
during before
and after
the
Results: There was no significant difference between the
inexercise.
endurance
sports
may
cause
many
potentially
serious,
An evaluation of about 4000 participremature race withdrawal rate in the analgesics cohort
unwanted
that increase
pants in AEs
a marathon
and with
half increasing
marathon analgesic
respect1
Pain Management
Center
and the cohort who did not take analgesics
(‘controls’).
dose.
endurance
sports
appears to
ively Analgesic
supports use
thisbefore
contention.
Serious
unwanted
DGS,
Bonn, Bad-Godesberg,
However, race withdrawal because of
gastrointestinal
AEs
pose
an
unrecognised
medical
problem
as
yet.
If verifiable
events occurred predominantly in users
of
Germany
was significantly more frequent in the
analgesics
cohort
inanalgesics.
other endurance
sports,
it
requires
the
attention
of
2
A benefit was not apparent.
Department of Experimental
than in the control. Conversely, withdrawal
because of
physicians and regulatory authorities.
Strengths and limitations of this study
and Toxicology, FAU
frequent in controls. The analgesicsErlangen-Nuremberg,
cohort had an almost
▪ This is the first investigation which relates
Hausarzt
unddrug
Spezialist:
5 times higher incidence of AEs (overall
risk Germany
difference of
unwanted
effects during endurance sports
Erlangen,
13%). This incidence increased significantly with
to the use of analgesics. The effect was signifi-
5. Mitteldeutscher
Schmerztag 2014
3
analgesics.
and CV problems in
atherosclerosis
4
Key message
patients.
▪ We hypothesised that the drugs taken before
sports may increase the incidence of cardiovascular, gastrointestinal and kidney damage
without lowering the pain during and after the
exercise. An evaluation of about 4000 participants in a marathon and half marathon respectively supports this contention. Serious unwanted
events occurred predominantly in users of
analgesics. A benefit was not apparent.
1
unwanted drug effects during endurance sports
to the use of analgesics. The effect was significant in OTC doses and increased with higher
doses. The incidence of organ damage was
about five times more frequent after analgesic
use. Serious events requiring hospital admittance
▪ In our study, the role of confounders, as preexisting joint pain, could not be excluded.
that physical activity does not automatically
result in better health, but could exacerbate
2
This
may be
cardiovascular (CV) Univ.-Prof.
disease.1 Dr.
med. Holger Gabriel
related
to the
ofund
cyclooxygenases
Lehrstuhl
fürinhibition
Sportmedizin
by non-steroidal anti-inflammatory
drugs Jena
Friedrich-Schiller Universität
(NSAIDs),
including
2.0 Licence; see
Open Access
cant in OTC doses and increased with higher
failure (post-ibuprofen ingestion), four with bleeds (postabout five times more frequent after analgesic
admittance.
▪ In our study, the role of confounders, as prein endurance sports may cause many potentially serious,
Downloaded from http://bmjopen.bmj.com/
onAEs
November
14, 2014
Publishedanalgesic
by group.bmj.com existing joint pain, could not be excluded.
unwanted
that increase
with -increasing
1
Research
pose an unrecognised medical problem as yet. If verifiable
Germany
that
physical
in other endurance sports, it requires the attention of
2
Downloaded from http://bmjopen.bmj.com/ on November 14, 2014 - Publi
Consumption of analgesics before sports increa
with 1% of the co
11% recorded pai
of controls) and 1
(compared with 2%
This may be
cardiovascular
(CV) disease.
Consumption of analgesics before
a
related to the inhibition of cyclooxygenases
non-steroidal anti-inflammatory drugs
marathon and the incidence of by(NSAIDs),
including
(OTC) analgesics, that are known to exacerINTRODUCTION
cardiovascular,
gastrointestinal and renal
Endurance sports are becoming increasingly bate atherosclerosis and CV problems in
However, recent research has shown some patients.
problems: apopular.
cohort
study
and Toxicology, FAU
Erlangen-Nuremberg,
Erlangen, Germany
1 2
Correspondence to
kay.brune@pharmakologie.
med.uni-erlangen.de
3
4
1
Küster M, Renner B, Oppel P, et al. BMJ Open 2013;3:e002090. doi:10.1136/bmjopen-2012-002090
Michael Küster,1 Bertold Renner,2 Pascal Oppel,2 Ursula Niederweis,2 Kay Brune2
e002090. doi:10.1136/
bmjopen-2012-002090
the journal online
bmjopen-2012-002090).
equally.
2.0 Licence; see
1
Germany
2
ABSTRACT
defining the use of analgesics and the relation between
OTC analgesic use/dose and adverse events (AEs)
during and after the race, a relation that has not been
analgesic consumption before sports; incidence of AEs in
was significantly more frequent in the analgesics cohort
than in the control. Conversely, withdrawal because of
5 times higher incidence of AEs (overall risk difference of
failure (post-ibuprofen ingestion), four with bleeds (postaspirin ingestion) and two cardiac infarctions (postaspirin ingestion). None of the control reported hospital
admittance.
in endurance sports may cause many potentially serious,
ARTICLE SUMMARY
Article focus
▪ Participation in endurance sports, as in a marathon, is growing worldwide.
▪ Many amateurs engage in occasional endurance
analgesics.
Key message
to the use of analgesics. The effect was significant in OTC doses and increased with higher
about five times more frequent after analgesic
use. Serious events requiring hospital admittance
▪ In our study, the role of confounders, as preexisting joint pain, could not be excluded.
Figure 1 Flow chart of the evaluation of the marathon/
half-marathon running cohort. After the elimination of
duplicates, almost 2000 questionnaires were returned from
each cohort. The distribution of marathon and half-marathon
runners was similar in each treatment cohort. If participants
entered races other than the marathon or half marathon (eg,
relays), or did not state which race they entered, they were
captured in the ‘other/not stated’ cohort (AE, adverse event).
Medication use bef
In total, 1931 re
racing, to retard
thereafter. They u
race. Most of the
prescription (onl
significantly more
men (42%).
The most frequ
used by 47% of t
(online suppleme
resorted to supr
100 mg). The sec
was ibuprofen, an
ingested ≥800 mg
dose). Aspirin wa
therapeutic doses.
etoricoxib, melox
although these dr
athletes and are
analysis (online su
Of all respond
not informed abo
nection with spor
table S1).
Events during and a
The incidence of
group: men 38±12, women 34±13 years). Most responin runners of the
dents had previous marathon experience (overall 87%).
marathon (18%
In the analgesics cohort, 20% had also taken analgesics
analgesic-related A
during training (men 26% vs women 14%), compared
significantly highe
does not automatically
5. Mitteldeutscher
Schmerztag 2014
that physical activity
Gemeinsam
gegen den Schmerz
result in better health, but
could exacerbate
1 2
This may be
cardiovascular (CV) disease.
group: men 38±12, women 34±13 years). Most respondents had previous marathon experience (overall 87%).
In the analgesics cohort, 20% had also taken analgesics
during training (men 26% vs women 14%), compared
The incidence of reported AEs was significantly higher
in runners of the full marathon compared with the half
marathon (18% vs 7%; p<0.001). Additionally, the
analgesic-related AE risk in the full marathon cohort was
significantly higher than in the half-marathon cohort
Figure 2 Risk of adverse events
(AEs) within study subgroups
before a
(unadjusted). Consumption
ORs wereof analgesics
estimated
by binary linear
regression
cardiovascular,
problems:
a cohort study
analysis. Almost
all subgroups
show enhanced risk for AEs after
analgesic use (ORs >1; error bars
represent 95% CI).
Downloaded from http://bmjopen.bmj.com/ on November 14, 2014 - Published by group.bmj.com
Open Access
Research
e002090. doi:10.1136/
bmjopen-2012-002090
Open Access
ABSTRACT
ARTICLE SUMMARY
Article focus
▪ Participation in endurance sports, as in a maradefining the use of analgesics and the relation between
analgesics.
Key message
the journal online
sports may increase the incidence of cardiovas(http://dx.doi.org/10.1136/
bmjopen-2012-002090).
exercise. An evaluation of about 4000 participremature race withdrawal rate in the analgesics cohort
pants in a marathon and half marathon respectMK and BR contributed
ively supports this contention. Serious unwanted
equally.
to the use of analgesics. The effect was signififor use under the terms of
2.0 Licence; see
admittance.
1
Downloaded
from http://bmjopen.bmj.com/
on November
14, 2014
- Published
group.bmj.com
Pain Management
Center
dose. Analgesic
use before
endurance
sports by
appears
to
Research
Germany
that physical
2
and Toxicology, FAU
Erlangen-Nuremberg,
Erlangen, Germany
This may be
a to the inhibition of cyclooxygenases
related
by non-steroidal anti-inflammatory drugs
marathon and the incidence of (NSAIDs), including ‘over-the-counter’
cardiovascular,
renal and CV problems in
Endurancegastrointestinal
sports are becoming increasingly and
bate atherosclerosis
popular. However, recent research has shown some patients.
1 2
Correspondence to
med.uni-erlangen.de
3
4
1
e002090. doi:10.1136/
bmjopen-2012-002090
the journal online
bmjopen-2012-002090).
equally.
ABSTRACT
3
ARTICLE SUMMARY
Article focus
analgesics.
Key message
5. Mitteldeutscher
Schmerztag 2014
Consumption of analgesics before sports increases CV, GI and renal problems
Figure 6 Adjusted adverse
Consumption
of analgesics
before a
event (AE) risks
for analgesic
use
and dose dependency.
There was
a significant dose/AE
relationship
problems: a cohort
study
and reported ORs increased with
increasing dose differences (dose
no = controls without analgesic
use). Adjusted ORs were
estimated by binary linear
regression using possible
confounders (error bars represent
95% CI).
Open Access
Research
e002090. doi:10.1136/
bmjopen-2012-002090
Open Access
ABSTRACT
ARTICLE SUMMARY
Article focus
analgesics.
Key message
the journal online
bmjopen-2012-002090).
equally.
2.0 Licence; see
admittance.
1
Downloaded
on November
14, 2014
- Published
group.bmj.com
Pain Management
Center
dose. Analgesic
use before
endurance
sports by
appears
to
Research
Germany
that physical
2
and Toxicology, FAU
Erlangen-Nuremberg,
Erlangen, Germany
This may be
a to the inhibition of cyclooxygenases
related
marathon and the incidence of (NSAIDs), including ‘over-the-counter’
cardiovascular,
renal and CV problems in
Endurancegastrointestinal
sports are becoming increasingly and
bate atherosclerosis
popular. However, recent research has shown some patients.
1 2
Correspondence to
med.uni-erlangen.de
3
4
1
e002090. doi:10.1136/
bmjopen-2012-002090
ABSTRACT
ARTICLE SUMMARY
AEs compared with controls (figure 6). This further
and 600 mg) were taken before and during the race
adjusted regression model showed a statistically signifitogether with large amounts of fluid.
5. Mitteldeutscher
cantly increased risk at rising doses, meaning
that
Four respondents (numbers 4–7, online supplemenSchmerztag
increasing the dose can increase the risk of AEs by three
tary 2014
table S4) reported hospital admittance
because
Univ.-Prof. Dr. med.
Holger Gabriel
Lehrstuhl
für
Sportmedizin
und
Hausarzt
und
Spezialist:
times (OR 3.2; 95% CI, 2.7 to 4.0, p<0.001, figure 6).
of GI bleeding (black stools and vomiting blood).
Finally, the association of analgesic use with distinct
Gastroendoscopic evaluation revealed at least one inter-
the journal online
bmjopen-2012-002090).
equally.
Article focus
analgesics.
Key message
ption of analgesics before sports increases CV, GI and renal problems
95% CI 5.31 to 15.39 vs 3.20; 95% CI 2.32 to
e 2)).
Consumption of of
analgesics
before a
were similar numbers
half-marathon
and
runners in the
analgesics
cohort
cardiovascular,
gastrointestinal
and renalcompared
ols.
imes higher incidence of each type of AE was
n the analgesics cohort compared with conall incidence 16% vs 4%, online supplemenS3; figure 3), with a calculated risk difference
he difference in the incidence of AEs between
horts was most prominent with respect to GI
d CV events (after the race). In the analgesics
cramps were the most frequent AE (reported
the cohort), followed by CV AEs after the race
he controls, CV AEs after the race were the
ently reported
AE (3%, online supplementary
and the incidence of
Notably, marathon
haematuria
was reported only in the
a cohort study
cohort. problems:
The differences
in the incidence of
re highly significant between the two groups
online supplementary table S3; figure 3).
ificant difference was found between the
cohort and controls in terms of premature 5.
rawal overall (online supplementary table S3,
Race withdrawal because of muscle cramps
ignificantly more often in controls (3% vs 1%,
Open Access
Research
e002090. doi:10.1136/
bmjopen-2012-002090
Open Access
ABSTRACT
ARTICLE SUMMARY
Article focus
analgesics.
Key message
the journal online
bmjopen-2012-002090).
equally.
2.0 Licence; see
admittance.
1
Downloaded
on November
14, 2014
- Published
group.bmj.com
Pain Management
Center
dose. Analgesic
use before
endurance
sports by
appears
to
Research
Germany
that physical
2
and Toxicology, FAU
Erlangen-Nuremberg,
Erlangen, Germany
Correspondence to
med.uni-erlangen.de
INTRODUCTION
Endurance sports are becoming increasingly
popular. However, recent research has shown
cardiovascular (CV) disease.1 2 This may be
(NSAIDs),
including
(OTC) analgesics, that are known to exacerbate atherosclerosis3 and CV problems in
some patients.4
e002090. doi:10.1136/
bmjopen-2012-002090
the journal online
bmjopen-2012-002090).
equally.
ABSTRACT
ARTICLE SUMMARY
Article focus
analgesics.
Key message
1
Figure 4 Reasons for premature termination of the race.
Rounded percentages are given in online supplementary table
S3. **p<0.01; ***p<0.001. Note: the absolute numbers are
small.
Mitteldeutscher
The overall risk for analgesic-related AEs was estimated
Schmerztag 2014
Dr. med. Holger Gabriel
at 5.1 (95% CI 3.9 to 6.7; p<0.001,
figureUniv.-Prof.
6), giving
a
Universität Jena
Gemeinsam
gegen den
Schmerz to harm’ of eight treated Friedrich-Schiller
‘number
needed
participants.
e frequent
in the analgesics
cohort
than
in controls
race withdrawal
in the analgesics
cohort
compared
with
Therefore,
subgroup parameters
in
Tothese
investigate
whetherwere
theincluded
incidence
of AEs was dosecontrols
(2%
vs
1%;
p<0.01,
online
supplementary
table
1 vs 955 respondents, p<0.001, online supplemen-a regression analysis which resulted in a comparable
S3; figure 4).
dependent, a risk estimation of the size of the dose was
adjusted analgesic-related risk of 3.0 (95% CI 2.1 to 4.1;
table S3;Joint
figure
5).
and muscle pain after the race were significantly
conducted.
The high dose resulted in a significantly
p<0.001,
figure 6).
more frequent in the analgesics cohort than in controls
To investigate
whether
of AEswith
was dosehigher risk
of the
AEsincidence
compared
the lower dose or con(1301 vs 955 respondents, p<0.001, online supplemendependent, a risk estimation of the size of the dose was
tary table S3; figure 5).
trols.The
Even
low-dose
group
presented a higher risk of
conducted.
highthe
dose
resulted in
a significantly
higher risk of AEs compared with the lower dose or controls. Even the low-dose group presented a higher risk of
Open Access
Research
e002090. doi:10.1136/
bmjopen-2012-002090
ABSTRACT
ARTICLE SUMMARY
Article focus
analgesics.
Key message
the journal online
bmjopen-2012-002090).
equally.
2.0 Licence; see
admittance.
1
Downloaded
on November
14, 2014
- Published
group.bmj.com
Pain Management
Center
dose. Analgesic
use before
endurance
sports by
appears
to
Research
Germany
that physical
2
Figure 3 Incidence of adverse events (AEs, derived from
online supplementary table S3). Rounded percentages are
given in online supplementary table S3. The differences
between the groups were all highly significant; p<0.001.
Figure 5 Percentage of runners experiencing muscle and/or
joint pain after the race. Rounded percentages are given in
online supplementary table S3. The differences are highly
significant (***p<0.001).
re 3 Incidence
of adverse events (AEs, derived from
Figure 5 Percentage of runners experiencing muscle and/or
4 marathon and
Küster M, Renner
al. BMJ
Open 2013;3:e002090.
doi:10.1136/bmjopen-2012-002090
the incidence
e supplementary
table
S3). ofRounded percentages
are B, Oppel P, etjoint
pain
after the race.
Rounded percentages are given in
n in online problems:
supplementary
online supplementary table S3. The differences are highly
a cohort study table S3. The differences
een the groups were all highly significant; p<0.001.
significant (***p<0.001).
Open Access
and Toxicology, FAU
Erlangen-Nuremberg,
Erlangen, Germany
Correspondence to
med.uni-erlangen.de
INTRODUCTION
Endurance sports are becoming increasingly
popular. However, recent research has shown
cardiovascular (CV) disease.1 2 This may be
(NSAIDs),
including
(OTC) analgesics, that are known to exacerbate atherosclerosis3 and CV problems in
some patients.4
1
e002090. doi:10.1136/
bmjopen-2012-002090
the journal online
bmjopen-2012-002090).
equally.
ABSTRACT
ARTICLE SUMMARY
Article focus
analgesics.
Key message
5. Mitteldeutscher
Schmerztag 2014
e002090. doi:10.1136/
bmjopen-2012-002090
ABSTRACT
ARTICLE SUMMARY
Article focus
investigated
to date.
Table 1 Incidence of adverse
events
(AEs) in relation to the analgesic
used
information and
experience.
using an n=913
online questionnaire.
Diclofenac
Ibuprofen
sports n=722
by taking over-the-counter (OTC)
▸ Prepublication history
and
analgesics.
High dose
High
dose
paper are available Low
online. To dose
Participants: 3913
of 7048
participants in the Bonn
Key message
marathon
2010
returned
their
questionnaires.
n=312
Low dose
n=410 that
n=220
▪ We hypothesised
the drugs taken before
the journal online n=693
sports
may
increase
the incidence of
number
ofcardiovasnumber
of
number
of
number
of
analgesic
consumption
before sports;
incidence of AEs
in
bmjopen-2012-002090).
cohort of analgesic users as compared to non-users.
(%)after the
reportswithout
(%) lowering thereports
reports (%)
reportsthe(%)*
AEs
pain during and
exercise. An evaluation of about 4000 particirace withdrawal rate in the analgesics cohort
marathon respectUrine blood MK and BR contributed6 (1) premature
5 (2)
5 (1) pants in a marathon and
45half(14)
equally.
because of gastrointestinal AEs
GI-cramp
16 (2) However, race withdrawal
5 (2)
52 (13)events occurred predominantly
89 (29)in users of
analgesics.
A
benefit
was
apparent.
GI-bleeding Received 12 September2 2012
(<1)than in the control. Conversely,
8 (4) withdrawal because of13 (3)
39not(13)
cramps was 0
rare,(0)
but it was significantly more40 (10)
Strengths and limitations
this study
CV—during race
2 (<1)muscle
28of(9)
CV—post race
4 (1) 5 times higher incidence
8 (4)
(31)
of AEs (overall risk difference44
of (11)unwanted drug effects97
during
endurance sports
Total (individuals)†
25
22
56
163
Attribution
Non-Commercial
temporary hospital
admittance: three for temporary kidney
of organ damage was
Drug related AE
4%
10%
14% doses. The incidence52%
2.0 Licence; see
incidence http://bmjopen.bmj.com
*Percentages relate to the corresponding
subpopulations
and
are
rounded
to the nearest whole number.
admittance.
†Number of individuals reporting Conclusions:
AEs (a single
individual
may
report
>1
AE).
The use of analgesics before participating
▪ In our study, the role of confounders, as prein endurance
sports may cause
many potentially
See online supplementary table S2
for definition
of dose
sizes.serious,
Downloaded from http://bmjopen.bmj.com/
onAEs
November
14, 2014
Publishedanalgesic
by group.bmj.com existing joint pain, could not be excluded.
unwanted
that increase
with -increasing
CV, cardiovascular;
GI, gastrointestinal.
1
Open Access
Research
Germany
that
physical
in
other
endurance
sports,
it
requires
the
attention
of
2
Aspirin n=141
Other analgesics n=175
Low dose n=102 High dose n=39 Low dose n=107 High dose n=68
number of
number of
number of
number of
reports (%)
reports (%)
reports (%)
reports (%)
7 (7)
11 (11)
9 (9)
3 (3)
11 (11)
25
25%
19 (49)
9 (23)
19 (49)
8 (21)
12 (31)
34
87%
1 (1)
4 (4)
1 (1)
5 (5)
3 (3)
11
10%
1 (2)
9 (13)
2 (3)
0 (0)
3 (4)
12
18%
This may be
cardiovascular
(CV) disease.
a
non-steroidal anti-inflammatory drugs
marathon and the incidence of by(NSAIDs),
including
(OTC)
analgesics,
that
are
known to exacerINTRODUCTION
cardiovascular,
Endurance sports are becoming increasingly bate atherosclerosis and CV problems in
However, recent research has shown some patients.
problems: apopular.
cohort
study
Correspondence to
med.uni-erlangen.de
1 2
did not investigate the association between
drugs and CV problems. Recently, we re
two-thirds of the participants of a marathon
sics before the start.21 This investigation
most athletes taking analgesics had taken sup
tic doses. Similar data were reported by G
However, these studies did not investigate
analgesics and premature race withdrawal, a
they systematically record the performanc
dence of AEs.
The current study was designed to test th
that cyclooxygenase inhibitors contribute to
ment of AEs, which is possible as these dru
protective effects of prostaglandins on GI, C
function. We hypothesise that their use
suspend the mucosa-protective and kidne
effects of prostaglandin E2 (PGE2)/prostacy
thus augmenting the damaging effect of
blood flow22 and oxygen supply for the GI
kidney.23 Moreover, it was postulated that ma
could decrease the barrier function of th
mucosa, further increasing the absorption
toxins from the gut,24 and that repeated i
the production of endothelium-produced P
CV stress, for example, intensive exercise, ma
atherosclerosis.1 2 25
This study analysed respondents for age,
status, drug use (including doses), race com
AEs that occurred during the race and aft
the best of our knowledge, this study shows
time that the administration of analgesics be
thon/half marathon can significantly increa
these increase with increasing analgesic
increased incidence of AEs is dramatic; for e
of respondents in the analgesics cohort repo
turia compared with 0% of controls. Mo
respondents reported hospital admittance
either temporary kidney failure, bleeding
cardiac infarctions. All these serious events
the analgesics cohort.
Altogether, these data do not support the
that taking analgesics before a race improve
to complete the race or to prevent AEs there
Four aspects of this study deserve a
discussion.
Analgesics taken prophylactically before racing
do not prevent pain
Analysis of the pain reported by respondents
after racing showed no major identifiable
gained from taking analgesics. Muscle c
reported as a reason for premature race with
ginally less frequently in the analgesics coho
with the control. Although the difference wa
( p<0.001), the small sample size does not all
conclusions to be drawn, particularly in the
the parameters of overall pain during the rac
tinal cramps. There were significantly mo
and Toxicology, FAU
Erlangen-Nuremberg,
Erlangen, Germany
3
4
1
e002090. doi:10.1136/
bmjopen-2012-002090
the journal online
ABSTRACT
ARTICLE SUMMARY
Article focus
analgesics.
Hausarzt
5. Mitteldeutscher
Schmerztag 2014
Key message
und Spezialist:
sports may increase the incidence of cardiovas-
JPP58(10).book Page 1298 Friday, September 8, 2006 8:20 AM
, 2006 8:20 AM
1298
Review Article
Majella E. Lane & Mi-Jeong Kim
CONVENTIONAL ACIDIC NSAIDs
Assessment and prevention of gastrointestinal toxicity
of non-steroidal anti-inflammatory drugs
JPP58(10).book Page 1295 Friday, September 8, 2006 8:20 AM
Majella E. Lane and Mi-Jeong Kim
BIOCHEMICAL EFFECTS
Review Article
DETERGENT-LIKE EFFECTS
Abstract
Non-steroidal anti-inflammatory drugs (NSAIDs) are widely used for analgesic, anti-inflammatory and, in the case of aspirin, for anti-thrombotic actions. The serious gastrointestinal sideJPP 2006, 58: 1295–1304
effects associated with these drugs are of concern and pose a significant obstacle to their use.
© 2006 The Authors
This
review
discusses
the pathogenic mechanisms by which the conventional acidic NSAIDs
Received
February
20, 2006
induce
gastrointestinal
Accepted
March 21, 2006toxicity, with particular emphasis on non-prostaglandin effects. MethAssessment and prevention of gastrointestinal
DOI
ods
of10.1211/jpp.58.10.0001
assessment of NSAID-induced enteropathy are reviewed, with particular emphasis on the
ISSN
0022-3573
use of functional measurement of NSAID-induced
changes in theanti-inflammatory
gastrointestinal tract. The
of non-steroidal
drugs
advances in our knowledge of the pathogenesis of these effects have resulted in the development of a range of novel NSAIDs. Where functional assessment of the effects of NSAIDs has
E. indicator
Lane and
Mi-Jeongchanges
Kim rather than
been employed, it appears to be more Majella
useful as an
of early-stage
a predictor of the effects of long-term NSAID exposure. Successful pharmaceutical strategies
now offer considerable promise for reducing the severity of NSAID damage to the gastrointestinal tract. The utility of intestinal permeability measurements for selection and assessment of
Abstract
these strategies is discussed.
pH EFFECTS
toxicity
A) LOCAL
Uncoupling of
oxidative phosphorylation
B) LOCAL OR SYSTEMIC
Villus contraction
Vascular ischaemia
Non-steroidal anti-inflammatory drugs (NSAIDs) are widely used for analgesic, anti-inflammatory and, in the case of aspirin, for anti-thrombotic actions. The serious gastrointestinal sideeffects associated with these drugs are of concern and pose a significant obstacle to their use.
Introduction
This review discusses the pathogenic mechanisms by which the conventional acidic NSAIDs
As with many therapeutic agents,
non-steroidal
anti-inflammatory
drugs on non-prostaglandin effects. Methinducethe
gastrointestinal
toxicity,
with particular emphasis
(NSAIDs) have their origin in the
recognition
that certain
plantsare
were
odshistorical
of assessment
of NSAID-induced
enteropathy
reviewed, with particular emphasis on the
observed to produce therapeutic effects
in diseasemeasurement
conditions. Salicylate-containing
use of functional
of NSAID-induced changes in the gastrointestinal tract. The
plants, such as the bark of the willow,
wereinused
ancient Egyptians
and Romans
to effects have resulted in the developadvances
our by
knowledge
of the pathogenesis
of these
relieve pain in childbirth and gout,ment
and of
in athe
Middle
AgesNSAIDs.
there are
written
records
range
of novel
Where
functional
assessment of the effects of NSAIDs has
of these plants being used to treat wounds,
inflammation
and
pain.
Pure
salicylic
acid
been employed,
it appears
to be
more
useful
as an indicator
of early-stage changes rather than
was obtained from plants in the early
19th century.
Whileofworking
forNSAID
Bayerexposure.
in the Successful pharmaceutical strategies
a predictor
of the effects
long-term
1890s, Felix Hoffman initiated now
the offer
synthesis
of commercial
quantities
of the of NSAID damage to the gastrointesticonsiderable
promise for reducing
the severity
acetylated form of salicylic acid: acetylsalicylic
acid. of
Bayer
introduced
this new
drug
nal tract. The utility
intestinal
permeability
measurements
for selection and assessment of
as “aspirin” in 1899 and that marked
beginning
of the development of NSAIDs
thesethe
strategies
is discussed.
Decreased ATP
Increased intestinal permeability
Inflammation from mucosal
exposure to bacteria, bile,
pancreatic secretions,
(Pierpoint 1997).
hydrolytic enzymes
Aspirin was initially used in the treatment of headaches and fever associated with colds
proteolytic
and influenza, and was eventually recognized as the standard for
the treatment of enzymes
pain and
Decreased
mucosal
prostanoids
C) SYSTEMIC
Inhibition of COX-1
i) Impaired repair
Decreased mucus production
Decreased mitosis
ii) Impaired microvascular
blood flow
Severe inflammation
and ulcers
inflammation in rheumatoid arthritisIntroduction
up until the mid-1970s. In the decades following the
discovery of aspirin there was very little
the treatment of
rheumatic
As development
with manyin therapeutic
agents,
the diseases
non-steroidal anti-inflammatory drugs
until the 1950s, partly because the mechanisms
development
of the disease
(NSAIDs) underlying
have theirthe
origin
in the historical
recognition that certain plants were
Figure
2 Mechanisms
of induction
non-steroidal
anti-inflammatory drug-induced gastrointestinal damage (adapted from Bjarnason & Thjodleifsson
were little understood. In the 1950–1960s,
the drugs
available
for the treatment
ofinpain
and of
observed
to produce
therapeutic
effects
disease
conditions.
Salicylate-containing
inflammation in rheumatic diseases included
aspirin
(and
the
other
salicylates),
aminopheplants,
such as the bark of the willow, were used by ancient Egyptians and Romans to
1999).
nols (phenacetin) and pyrazolones (discovered
in the
1900s)and
andgout,
phenylbutazone.
The
relieve pain
in early
childbirth
and in the Middle
Ages there are written records
inhibition of the cyclooxygenase (COX)
enzyme
and being
subsequent
in prostaglandin
of these
plants
used reduction
to treat wounds,
inflammation and pain. Pure salicylic acid
synthesis was proposed as the major mechanism
of action
NSAIDs
in 1971
1971). While working for Bayer in the
was obtained
from of
plants
in the
early(Vane
19th century.
By
the
beginning
of
the
1990s,
a
large
range
of
chemically
diverse
NSAIDs
wereof commercial quantities of the
1890s, Felix Hoffman initiated the synthesis
Department of Pharmaceutics,
available,
which shared
actions
and adverse
effects. The disdiagnosing NSAID enteropathy (Meling et al
1996; Tibble
School of Pharmacy,
29–39a variety of pharmacological
acetylated form of
salicylic
acid: acetylsalicylic
acid. Bayer introduced this new drug
Brunswick
London, isoform of
covery
of Square,
an inducible
COX-2,
in addition
the constitutively
as COX,
“aspirin”
in 1899
and that to
marked
the beginning of the development of NSAIDs
WC1N 1AX,
UK
Functional
may be broadly divided into et al 1999).
expressed
COX-1
isoform, required (Pierpoint
a refinement
of the theoryinvestigations
that non-specific inhibition
1997).
111
Lane
ofMajella
COX E.activity
explained both therapeutic
and
side-effects
of
NSAIDs
(Herschman
Aspirin
was initially used
in thethe
treatment
of headaches andindium
fever associated
with colds ), use
scintigraphy
with
radioisotope
(indium
1994). Subsequent pharmacologicaland
results
suggested
thateventually
selective recognized
COX-2 inhibition
influenza,
and was
as the standard for the treatment of pain and
Intestinal function tests
Gastrointestinal, Pulmonary and
Assessment of intestinal permeability
Permeability changes
2
0
0 mg
325 mg
650 mg
975 mg
Physiology & Biochemistry
0.01
0
421
0 mg
325 mg
650 mg
975 mg
424 Physiology & Biochemistry
Fig. 2
Urinary excretion of sucrose, lactulose, rhamnose and the lactulose-to-rhamnose ratio (L/R) during the aspirin portion of the study. Asterisk (*)
Effindicates
ect of signifi
Aspirin
Dose on Gastrointestinal Permeability
Gastrointestinal
complaints
cant (P < 0.008) difference compared to the placebo (0 mg) condition. All data
are presented as median (range).
Lactulose excretion (% of ingested dose)
Sucrose excretion (% of ingested dose)
0.35
*
0.45
(0.28 –0.75)
0.5
*
0.54
(0.33 –0.82)
0.46
(0.36 –0.68)
0.3
week).
Thus, it is not* necessary to control for the menstrual cycle
0.240
–0.2)
0.25
when
studying GI (0permeability
in 0.4women. Similar results have
Authors0.2
G. P. Lambert , A. Schmidt , K. Schwarzkopf , S. Lanspa
been shown with
regard to other GI
0.3 functions such as motility
Creighton University, Exercise Science, Omaha, United States0.21
Affiliations
Creighton University,
0.15 gastric emptying
and
[4Medicine,
, 18]Omaha,
. United States (0.11 –0.37)
0.102
0.2
(0.01 –0.43)
In 0.1conclusion,
acute aspirin ingestion leads to significant
0.1
increases
in GI permeability. Because
GI barrier dysfunction can
0.05
0.007
(0
–0.2)
Abstract
urinary excretion of ingested probes. Sucrose
Key words
cause GI symptoms
and possibly more
severe effects, athletes
0
● gut 0
(5 g) was used to determine gastroduodenal
▼
975 mg
0
mg
325 mg
650 mg
975
mg
325
mg
650
mg
0
mg
● menstrual cycle
The primary purpose of this study was to deterpermeability. Lactulose (5 g) and rhamnose (2 g)
be cautioned
about
the
use
of
aspirin
prior
to
(or
during)
athletes
●should
mine the aspirin dose that increases gastroinwere used to assess small intestinal permeability
testinal (GI) permeability. A pilot study was
via the lactulose-to-rhamnose urinary* excretion
0.07also
10
events
that could
be
infl
uenced
by
GI
function and/or the0.063
events
conducted to determine whether the menstrual
ratio (L/R). The data indicated that(0.04
menstrual
–0.11)
0.059
8.5
cycle affects GI permeability. Both portions of
cycle had no effect on
GI–0.10)
permeability. In con(0.04
(6.3 –10.6) affect
8.0 aspirin’s
0.06 on GI permeability.
that could exacerbate
7.8
the study (6.0
involved
trast, gastroduodenal
permeability was signifi0.052
–12.6) 4 experimental conditions.
1
1
2
1
1
2
▶
▶
(4.7 –15.8)
6
5.6
(1.6 –9.8)
(0.04
–0.07) increased following a dose of
For the aspirin portion, 8 subjects ingested 0 mg,
cantly (P
< 0.008)
0.05
325 mg, 650 mg, or 975 mg of aspirin the
night
650 mg aspirin and small intestinal permeability
before and the morning of an experiment. For 0.038
(L/R) was significantly (P < 0.008) increased folthe menstrual cycle pilot study, 5 female
lowing a dose of 975 mg aspirin. These results
(0.03 –0.07)
0.04subjects with regular menstrual cycles were tested
suggest healthy individuals should be cautious
for GI permeability on the same day each week
even with acute aspirin use as it may result in GI
for 4 weeks. GI permeability was assessed0.03
by the
barrier dysfunction.
Acknowledgements
▼
4
Lactulose-to-Rhamnose Excretion Ratio (L/R)
Rhamnose excretion (% of ingested dose)
▶
8
among athletes
*
0.6
This study was
conducted with0.02funding
from(342the
Gatorade
Background
include sucrose
Da) which
assesses gas2
troduodenal
permeability
since
it is not digested
▼
0.01
Sports ScienceAthletes
Institute.
commonly use non-steroidal antiuntil it reaches the small intestine [17]. To assess
inflammatory drugs (NSAIDs) for anti-inflammasmall intestinal permeability, lactulose (342 Da)
tory and analgesic purposes. As a matter of0fact,
is commonly used. It is not hydrolyzed until it
accepted after revision
325large
mg intestine
650 mg
975 mg bacte0 mg
325endurance
mg
650
mg are 975
mg to ingest such 0 mg
athletes
known
reaches the
(i.e, by colonic
December 23, 2011
drugs both before and during events [6]. Howria). A readily absorbed control probe is also
Fig. 2 Urinary excretion of sucrose,
lactulose,
rhamnose
andaspirin,
the lactulose-to-rhamnose
ratio (L/R)normally
during theemployed
aspirin portion
the study.
(*)
ever,
NSAIDs,
such as
are known to cause
to ofcontrol
forAsterisk
non-mucosal
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should
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Creighton University
response. Endotoxemia has been observed
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6 FrednonHL. The 100-mile
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performance,
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Fax: +1/402/280 4732
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of a blunted satellite cell response in the NSAID
group. It is known, however, that satellite cells are
necessary for muscle maintenance, growth and
or a negative influence of NSAIDs
regeneration as a source of new myonuclei and
tudies that have focussed on the cymyoblasts, so a block or delay in these processes
(COX) pathway, the target of NSAID
could reduce the maintenance level or enhanced
ulture and animal models show quite
OX activity and its downstream A.
prosms
L. Mackey muscle mass that would otherwise have been gained
Use of anti-inflammatory medication in healthy
Gs)
are important
forof Sports
skeletal
muscle
d,
Institute
Medicine
Copenhagen in the absence of NSAIDs. It is possible that
st
Bispebjerg
Hospital for
and Faculty
of Health at
Sciences such
athletes
– no in
pain,
no gain?
a block
satellite
cell proliferation could
This
has been
shown
myoblasts
nt
University of Copenhagen
explain the reduced hypertrophy observed with
s of proliferation, differentiation Copenhagen
and
ng
er
Denmark NSAID
Scand J Med
Sci Sports
17: 613–614
ingestion
in 2007:
the rat
study by Bondesen
ermore, several studies using animal
E-mail: [email protected]
in Singapore . All rights reserved
etPrinted
al. (2006).
hown that inhibition
of COX activity
DOI: 10.1111/j.1600-0838.2007.00738.x
Since
the discovery
ofhere,
aspirin
the latter
The findings
mentioned
takenintogether
with part
cle regeneration. Convincing data from
others,
to a negative
NSAID
dy indicate that inhibition of COX
of the point
nineteenth
century,influence
a host of nonsteroidal
Mackey
ingestion
on the normal
response
of skeletal
estion of Ibuprofen can attenuate overanti-inflammatory
drugs
(NSAID)
hasmuscle
emerged,
nti-inflammatory
Am J Physiol Endocrinol Metab 2002:
to
exercise inpain
humans.
While
precise
mechanisms
providing
relief
in the
many
disease
conditions.
n exercise-induced
282: E551–E556.
cursor cell responses in
Warner DC, Schnepf G, Barrett MS,
by
which thisthe
occurs
remainworld,
to be fully
uncovered,
Naturally,
sporting
where
pain613(albeit
pl Physiol 2007: 103:
Dian D, Swigonski NL. Prevalence,
attitudes, and behaviors related to the the current knowledge certainly urges caution against
often self-imposed) is commonplace, has also taken
ite F, Lambert CP, Cesar
use of nonsteroidal anti-inflammatory
the
casual use of NSAIDs, especially in the treatment
M, Evans WJ. Effect of
drugs (NSAIDs) in student athletes.
advantage
of the analgesic properties of NSAIDs.
d acetaminophen on
Journal of Adolescent Health 2002:
of DOMS. Perhaps it is more beneficial in the long
muscle protein synthesis.
30: 150.
Athletes take this type of medication in order to
run to put up with the pain (where possible) in order
continue
training
when faced with injury, to alleviate
to
maximise
the gain.
take a great effort to initialise in the
Editorial
load-in
2006).
on the
synerg
was ob
Bispebje
in the
compa
sumed
it invo
animal
delayed-onset muscle soreness (DOMS), and also
trainin
on
a prophylactic
basis. While
it is difficult
to get a
Use
of anti-inflammatory
medication
in healthy
In h
handle
on –the
athletes
noextent
pain, of
no NSAID
gain? use in this populaReferences
muscle
tion, there have been reports suggesting, for example,
cells h
that up to one in seven adolescent
high school
Bondesen BA, Mills ST, Pavlath GK. The
influence of anti-inflammatory
lowing
football
players
takes
NSAIDs
on
a daily
basis
COX-2 pathway
regulates
growth
of
medication
on exercise-induced
atrophied muscle
via 2002),
multiple and, although
myogenic
precursor
cell
responses
Univ.-Prof. Dr.
med.
Holger
Gabrielin
least
1
(Warner
et al.,
the
concern
Since
the
discovery
of
aspirin
in
the
latter
part
Lehrstuhl
für
Sportmedizin
und
mechanisms. Am J Physiol Cell Physiol
humans. J Appl Physiol 2007: 103:
Friedrich-Schiller Universität
Jena
fractio
about
chronic
NSAID
use
has
centred
on
of
century, a host
of potential
nonsteroidal
2006:the
290: nineteenth
C1651.
425–431.
Editorial
1,2
1,3
1
1
1
2
3
-induced rise in patella
2
2
2
2
interstitial PGE2 and abolished the exercise-induced adaptive increase
in collagen synthesis in human tendons.
inflammation; NSAID; type I collagen
needed before it is possible to understand the pathology fully.
The purpose of the present study was to analyze the effect of
NSAID on the local peritendinous concentrations of PGE2 and
patella tendon collagen synthesis in response to an acute bout
of endurance training. This was done to clarify the relationship
between collagen synthesis and PGE2 levels by monitoring the
effect on collagen synthesis when PGE2 release is blocked by
NSAID. Based on previous findings, it was hypothesized that
the treatment with NSAID would lead to a decrease in PGE2
levels. Given that PGE2 is a growth factor for collagen tissue,
NSAID treatment would then lead to a decrease in the exerciseinduced increase in collagen synthesis.
Downloaded from on November 26, 2014
2
2
Downloaded from
©
Downloaded fr
shown exercise
to stimulate
the 32)
synthesis
of prolonged training (22) by collagenase levels increased, while the hydroxyproline content
(14,AND 24,
HUMAN SKELETAL MUSCLES
tendons are as
both well
known as
to
tro. respond
We increasing
have
performed
a
number
of
and
adapt to
altered
levels
of
physical
activity
by,
e.g.,
collagen type I synthesis. In addition, studies using was unchanged, indicating a net increase in collagen degradahypertrophy and increased collagen synthesis (18, 29). Several
wing
that
several
of
the
above-menstudies the
have shown
that acute
of exercise,
as well as
flexorofdigitorum
profundus
teninfusion
ofbouts
stable
isotopes,
potentially a more direct mea- tion after stretching of
Fig.avian
2. Effects
PGE2 blockade
on collagen
training, in
induces
changes in local metabolism,
inare prolonged
increased
concentration
in
resynthesis in
thethe
patella
tendon. Measurements
of
that
increased
PGE2 producsureactivity,
of collagen
the same adaptive response dons (8). This could indicate
flammatory
and collagensynthesis,
turnover in theshowed
Achilles
9 –21,
peritendinous
concentrations
of
NH
tendon23).
(14,
24),
resulting
in an increased
formation
of the
type Ipatella tendon with increased
2-terminal
tion
seen
in
relation
to
exercise/stretching
could
play
some
role
to
a
1-h
kicking
exercise
in
in the hours and days following the loading (14, 24,
propeptide
of
type
I
(PINP)
before
and
72
h
after
a
)
are
known
to
be
the collagen
eicosanoid
PGE
METHODS
2 human patella
in tendon collagen degeneration.
In
support
of
PGE
collagen
formation
(31).
being
a
32). Along
the same line,
the
tendon has also
2
36-km run and placebo treatment (n " 6) (A) or
been
shown
to
demonstrate
adaptive
potential
with
markedly
Subjects. A total of 15
young men
were included
in the factor for collagen synthesis, previous in vitro studies
matory
response
in humans
(6). Newly
growth
The synthesis
adaptive
response
collagen
inhealthy
human
tenNSAID treatment (n " 7) (B). Bars represent
increased collagen
in response
to exercisein
(31).
This presentsynthesis
study (Table 1). They were randomly assigned into two groups
demonstrated
that
prostaglandin
contransformation
of
mechanical
forces
to
biochemical
and
struc(by
envelope):
one
group
(n
"
8)
receiving
placebo
(calcium
tablets)
ofSE,
PGE
dons to loading is thought to be mediated through a combina- have shown that blockade
by indomethacin
means #
*P 2$release
0.05.
tural responses (15) involves a number of different growth and the other group (n " 7), indomethacin (oral intake starting 72 h
interstitial
tissue
can
be blocked
by on
priorthe
to exercise
continuing
72 h postexercise; 100 mg
Confortid in a decrease in DNA synthesis (4), cell proliferation,
results
tionsuch
of
direct
mechanical
loadandon
the fibroblasts
factors (18),
asaIGF-I
(1), transforming
growtheffect
factor-$
twice a day). Indomethacin is an NSAID that inhibits both cycloox(TGF-$)
(14,
36),
PDGF-bb
(5),
IL-6
(Andersen
MB,
Pingel
J,
sionKjaerofM,and
NSAID
(20, 30).
Studiessubstances,
in
the release
of various
such as different cyto- and tendon glycosaminoglycan synthesis (35). Thus, the inLaugberg H, unpublished observation), and IL-1$ ygenase-1 (COX-1) and COX-2 and thereby the production of PGE .
The included subjects were all experienced runners, were training for
own thatkines
NSAID
canIL-6)
block
thegrowth
adaptive
(e.g.,
and
factors
(e.g.,andTGF-!,
a marathon,
were able to IGF-I)
run 36 km in(28).
less than 3 h. crease
None of the in collagen synthesis in the present study could be partly
subjects
suffered
from
any
tendon
injuries
within
the
last
year or had
for reprint requests
and
correspondence:
H. Langberg,
Insti- to be elevated during and
ells,tuteAddress
the
stem
ofotherskeletal
muscles,
mediated
through the increase in PGE2. Several studies have
PGE
levels
have
been
shown
2 cell
of Sports Medicine
Copenhagen, Bispebjerg Hospital, Bispebjerg bakke been taking any kind of medication within the last half year. All
gave written
informed consent totissue
participate in the
study after
23, 2400 Copenhagen
NV, Denmark
(e-mail: [email protected]).
ertrophy
of skeletal
muscle
in response
immediately
after
exercise
locallysubjects
in the
peritendinous
analyzed
the effect of PGE2 blockade on the collagen tissue
J
Appl
Physiol
•
VOL
110
•
JANUARY
2011
•
www.jap.org
Copyright 2011 the American Physiological Society
137
her http://www.jap.org
PGs(20,
play
roleand
in8750-7587/11
the potentially
adaptive
23,a 24)
thus
play a role in the exercise- supporting
the findings from the present study. In a study by
2
oaded from on November 26, 2014
kines (e.g., IL-6) and growth factors (e.g., TGF-!, IGF-I) (28). crease in collagen synthesis in the present study could be partly
PGE2 levels have been shown to be elevated during and mediated through the increase in PGE2. Several studies have
Effect
of anti-inflammatory
medication
rise in patella
immediately
after exercise
locallyon
in the
therunning-induced
peritendinous tissue
analyzed the effect of PGE2 blockade on the collagen tissue
tendon
humans play a role in the exercise- supporting the findings from the present study. In a study by
(20,collagen
23, 24)synthesis
and thusinpotentially
induced
adaptive response in collagen synthesis (14, 22, 24, 31, Ferry et al. (9) it was found that COX-2 inhibitors given in the
Britt Christensen, Sune Dandanell, Michael Kjaer, and Henning Langberg
32).Institute
As ofPGE
postoperative period after injury at the osteotendinous junction
concentration
canHospital,
be manipulated
Sports 2Medicine
Copenhagen, Bispebjerg
and Center of Healthyby
Aging,reducing
University of Copenhagen,
Denmark; Department of Endocrinology and Internal Medicine, NBG/THG, Aarhus University Hospital,
theCopenhagen,
interstitial
concentration through an intake of NSAID (13), in rabbits, resulted in significantly decreased levels of hyAarhus, Denmark; and Faculty of Health, Care and Rehabilitation, School of Physiotherapy, Metropolitan University
it isCollege,
possible
to Denmark
test this hypothesis. Several studies have stated droxyproline, a marker for collagen synthesis, compared with
Copenhagen,
Submitted
16 August 2010; accepted in final
24 October 2010
that
a prolonged
asformthe
J Appl
Physiol 110: run
137–141,
2011.present one used leads to an the placebo group. This resulted in a detrimental effect on
increased
release
various
(11, to21,
23). the synthesis
tendonof healing strength, with the tendons treated with COX-2
Christensen
B, Dandanell
S, Kjaer M,of
Langberg
H. Effectinflammatory
of anti- (10), which factors
28, 2010;
doi:10.1152/japplphysiol.00942.2010.
have been shown
stimulate
inflammatory medication on the running-induced rise in patella tendon collagen, at least in vitro. We have performed a number of
In addition, in vitro studies have
shownCOLLAGEN
that
a regimen
of cyclic
inhibitors
being significantly weaker than the control tendons
collagen synthesis in humans. J Appl Physiol 110: 137–141, 2011.
First studies
TENDON
SYNTHESIS
ANTI-INFLAMMATORY TREATMENT
139
on humans showing
that several AND
of the above-menpublishedmechanical
October 28, 2010;stretching
doi:10.1152/japplphysiol.00942.2010.—
of
human
tendon
fibroblasts
an
(9).
tioned growth
factors areresults
increased in
in concentration
inIn
re- a rat study by Forslund et al. (12), it was found that
NSAIDs are widely used in the treatment of inflammatory diseases as
sponse to exercise (8, 19 –21, 23).
well as increased
of tendon diseasesproduction
associated with painof
in sports
and
PGE
indomethacin
treatment resulted in a significantly reduced
and COX
by the
fibroblasts
in a) are known
2 labor.
to be
Prostaglandins
(e.g.,
the eicosanoid PGE
However, the effect of NSAID intake, and thus blockade of PGE
involved (4,
in the25,
inflammatory
response in humans cross-sectional
(6). Newly
stretching
frequency-dependent
manner
39).
area of the tendon regenerate, but failure load
production,
on the tendon tissue
adaptation is unknown. The purpose
performed
studies
have
demonstrated
that
prostaglandin
conof the present study was to elucidate the possible effects of NSAID
Thetendon
consequences
of these
elevated
levels
oforPGE
On the other side, protein synthesis (measured
centration
in plasma
interstitial
tissue can be was
blockedunchanged.
by
2 during
intake on healthy
collagen turnover in relation
to a strenuous
bout of endurance exercise. Fifteen healthy young men were randomly ingestion or local infusion of NSAID (20, 30). Studies in
exercise have been addressed in previous studies, showing that as an increase in 3H-proline incorporation) has been found to
assigned into two experimental groups, with one group receiving skeletal muscle have shown that NSAID can block the adaptive
Fig. 1. PGE2 blockade in the patella tendon. Meaindomethacin
(oral tendons
2 ! 100 mg Confortid
daily for
7 days;PGE
NSAID; had
activation
of satellite cells, the
stem cell of
of skeletal
muscles,
rabbit
injected
with
be
increased,
which
could
indicate
thattendon
the synthesis
of concencollaa
predominant
pattern
2
surements
of patella
peritendinous
n " 7) and a placebo group (n " 8). Both groups were exposed to a and thus reduce the hypertrophy of skeletal muscle in response
1bout of running (36 in
prolonged
km). the
The collagen
synthesis
NH - towith
degeneration
tendon
matrix,
decreased
gen
molecules is actually
by PGE
(4).run
loadinga(27).
Whether PGscollagen
play a role in the
adaptive
trationsstimulated
of PGE2 before
and 722 hinhibition
after a 36-km
angberg
terminal propeptide of type I (PINP) and PGE concentrations were response in connective tissue is at present, however, not
after placebo
treatment
" 5) (A) lead
and NSAID
fibril
diameter
of parallel
collagen
organization
In ofthe present study,
the intake
of(nNSAID
to a
measured
before and
72 h followingand
the runloss
in the patella
tendon by known.
NSAID fiber
is often the
drug of choice in the treatment
hy Aging,
University
of concentrations
Copenhagen,
microdialysis.
The peritendinous
of PINP increased
" 6) (B). Bars represent
means #
SE,
inflammation,
e.g., tendinopathies,
soft tissue,
and ligamentous
(17).
is supported
byas additional
studies
showing
that
significant
reductiontreatment
in the (n
exercise-induced
collagen
synsignificantly
in theThis
placebo group
as a result of the run,
shown
injuries
(3).
Considering
the
wide
use
of
NSAID,
the
physio/THG,
Aarhus
University
Hospital,
$ 0.05.
previously.
PGE levels
were significantly
decreased 72 h after the run
exogenous
thesisto in the patella*P tendon
(Fig. 2). Unfortunately, no
both
vitro
of are important
logicalin
effects
of thisproliferation
drug on the tendon tissue
2 decreased
compared
with basal levels inPGE
the subjects
treated with NSAID
and the
understand
for
optimizing
the
treatment
of
patients
with
tenotherapy,
Metropolitan
University
unchanged
in the placebo
group. The
NSAID intake
abolished the and the collagen production
human
patellar
tendon
fibroblasts
measurements were performed immediately after exercise in
adaptive increase in collagen synthesis in the patella tendon found in dinopathies and other tendon disorders (34). However, a full
understanding
of the effects of
PGE and
the use ofthe
NSAID
in
the placebo
group in response
to thethe
prolonged
exercise (Pgroup
# 0.05). (7).
compared
with
placebo
Furthermore,
PGE
present
study, but a significant lowering of the PGE2
2 and
The present study demonstrates that intake of NSAID decreased relation to mechanical loading in healthy tendon tissue is
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Indometacin + körperliches Training —> Mortalität
NSAID —> Morbidität + Mortalität
„Präventive“ intraartikuläre Kortikoidinjektionen —> Morbidität
(?)
5. Mitteldeutscher
Schmerztag 2014
(Erwünschte und unerwünschte) Verhaltensänderung:
Analgetikaeinnahme durch medizinische Laien.
Selbstwert Selbstwirksamkeit Identifikation
Ergebniserwartungen
Ziele und Planung
Absicht
Aufrechterhaltung
Stabilisierung
Risikowahrnehmung
Barrieren und
Ressourcen
Absichtsbildung / Motivation
Bewusstwerden
Vorbereitung
Stufenmodell der Verhaltensänderung
(Prochaska, DiClemente, Norcoss, 1992)
Erholung
Handlung
Handlung
Aufrechterhaltung
Stabilisierung
Angelehnt an:
Prozessmodell gesundheitlichen Handelns (HAPA);
Schwarzer, 1996 ff.
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(Andauernde) Leistungsmaximierung, Krankheitsprävention, Gesundheitsförderung
Intention, Motivation, Selbstwirksamkeit, Risikoabschätzung, Ergebniserwartung, Barrieren
5. Mitteldeutscher
Schmerztag 2014
Sportmedizinisches Selbstverständnis
Sportmedizin ist aus wissenschaftstheoretischer Sicht (wie die Medizin an sich) eine
praktische Wissenschaft. Sportmedizin ist keine angewandte Naturwissenschaft.
Die Grundaufgaben der Sportmedizin sind die Menschenangemessenheit, die Gestaltung
der zwischenmenschliche Begegnung zwischen Arzt und Patient* (Sportler) sowie die
Wissenschaftlichkeit.
Inhalt der sportmedizinischen Gesundheitssprechstunde ist der medizinische Umgang mit
Bewegung, Übung, Training und Sport bei gesunden und kranken Menschen jeglichen
Alters, beiderlei Geschlechts, jeglicher Leistungsfähigkeit, mit und ohne Handicap.
Sportmedizinisches Handels soll beitragen zu den subjektiven Zielen einer gesunde
Lebensführung des Patienten (Sportlers): 1. Funktionsfähigkeit (primär: physisch; sekundär: seelisch, sozial)
2. Umgangsfähigkeit mit Gesundheit und Krankheit
3. Ermöglichung letzter Lebensziele (Beitrag zu einem gelingenden Leben)
*Status- und Funktionsbezeichnungen gelten unabhängig von ihrem grammatikalischen Geschlecht für Männer und
Frauen gleichermaßen. Ausnahme: Explizite Hervorhebung aus inhaltlichen Gründen.
Theoretische Grundlagen der sportmedizinischen Gesundheitssprechstunde:
Ziele sportmedizinischen Handelns
Krankheitsprävention und Umgang mit Krankheitsfolgen ...
... bei bewegungsarmer Lebensweise
1. Innere Krankheiten (metabolisch, cardiovaskulär,
pulmonal, immunologisch, neurologisch, gastrointestinal)
2. Krebserkrankungen
3. Neurologische und muskuloskelettale Erkrankungen
4. Veränderungen des Immunsystems
5. Sarkopenie
6. Verminderte Lebensqualität und Lebenserwartung
Inactivity and obesity as risk factors for developing diseases
Handschin C., Spiegelman B.M.: Nature 454(7203) 463-469, 2008
... bei (hoch-) aktiver Lebensweise
1.
Plötzlicher Herztod
2.
Überlastungsschäden
3.
Übertrainingssyndrom
4.
Traumata und Folgen
5.
Akute und chronische Erkrankungen
6.
Medikamenten-/Substanzmissbrauch
7.
.
.
Ggfs. verminderte Lebensqualität und geringere
Lebenserwartung
Ziele des sportmedizinischen Handelns
1. Gesundheitsförderung ➔ Abbau von Krankheitsrisiken, Therapie und Ressourcenstärkung
2. Funktionsfähigkeit ➔ Erhalt, Wiederherstellung, Optimierung
3. Umgangsfähigkeit ➔ Sportärztliche Hilfe im angemessenen Umgang mit Altern, Gesundheit, Krankheit
Theoretische Grundlagen der sportmedizinischen Gesundheitssprechstunde:
Normative Rahmenbedingungen
Mensch sein dürfen
ab
wie
en
ge
An
rso
rge
n
Pflichten
Vo
rg
Fü
ige
äd
eit
nh
ch
hts
se
Nic
Rechte
Selbstbestimmte,
selbstverantwortete
Lebensführung
it
ke
m
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sf
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nk
Fu
Gerechtigkeit
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Selbstbestimmung, Fürsorge, Nichtschädigen
5. Mitteldeutscher
Schmerztag 2014
3
2
1
4
körperlich
Krankheit
- Funktionsfähigkeit
seelisch
Umgangsfähigkeit
Selbstverantwortete Lebensführung als Ziel
iel:
Z
es e
h
c
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tl
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vid ung
S
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f
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(L
tt ngs
e
W s tu
Lei
Gesundheit
+ Funktionsfähigkeit
sozial
1 Befähigung zu (wieder) mehr Funktionsfähigkeit
2 Prävention der Verminderung der Funktionsfähigkeit, ggf. Beitrag zur Minimierung einer unvermeidbaren Reduktion
3 Befähigung zu (wieder) mehr Umgangsfähigkeit (mit je aktueller Funktionsfähigkeit)
4 Prävention der Verminderung der Umgangsfähigkeit, ggf. Beitrag zur Minimierung einer unvermeidbaren Reduktion
Gesundheit - Erkundungen zu einem menschenangemessenen Konzept
Hans-Martin Rieger; ThLZ.F 29, Leipzig 2013 240 Seiten
Friedrich-Schiller-University of Jena
Sports Medicine and Health Promotion
Leistungsoptimierung in der sportmedizinischen Gesundheitssprechstunde
Holger Gabriel; In: Nikolaus Knoepffler (Hrsg.): Der optimierte Mensch.
Kritisches Jahrbuch der Philosophie, 2013, S. 141-160
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Selbstbestimmung, Fürsorge, Nichtschädigen
Selbstverantwortete Lebensführung
5. Mitteldeutscher
Schmerztag 2014
Akute körperliche Beanspruchung wirkt
Sport birgt
Sport zieht
pro- und antiinflammatorisch
schmerzfördernd und schmerzhemmend
Verletzungs-, Überlastungs-,
Unfall- und Gewaltgefahren
die Beanspruchung diagnostischer,
therapeutischer und rehabilitativer
Ressourcen nach sich
Die Einnahme von Analgetika im Sport ist sehr wahrscheinlich (allgemein, Einzelverlauf).
Welche Indikation ist angemessen?
Wer ist für die Einnahme von
Analgetika verantwortlich?
Präventiv? Therapeutisch? Rehabilitativ?
Gesundheit? Leistung? Adaptation?
Arzt, Patient, Sportler, Berufstätige, Soldat, „Jedermann“, „Jederfrau“, Süchtige, Erziehungsberechtigte, Vormund
Informationen über Wirkungen und Nebenwirkungen von Analgetika sind allgemein verfügbar.
Die Einnahme von Analgetika setzt eine medizinische Indikation voraus.
Die ethischen Prinzipien der Selbstbestimmung, des Nichtschädigens („primum nihil nocere“)
und der Fürsorge sind essentieller Bestandteil des Arztethos.
5. Mitteldeutscher
Schmerztag 2014
Analgetikaeinnahme, wer ist verantwortlich?
"Nicht bloß der Arzt (Red.: und Ärztinnen) muss bereit sein, das Erforderliche zu leisten,
sondern auch der Kranke (Red.: Sportler und Sportlerinnen) selbst
und seine Pfleger (Red.: Trainer und Trainerinnen)
und die äußeren Lebensbedingungen (Red.: Gesellschaft).“
Hippokrates, *um 460 v. Chr., † um 370 c. Chr., Griechischer Arzt
Analgetika im Sport - keine unterschätzte Gefahr!
VERBOTSLISTE 2014
WELT-ANTI-DOPING-CODE
Inkrafttreten: 1. September 2014
- Informatorische Übersetzung -
In Einklang mit Artikel 4.2.2 des Welt-Anti-Doping-Codes gelten alle verbotenen
Substanzen als „spezifische Substanzen“ mit Ausnahme der Substanzen in den Klassen S1, S2, S4.4, S4.5 und S6.a sowie der verbotenen Methoden M1, M2 und M3.
NADA - Nationale Anti Doping Agentur für Deutschland
SUBSTANZEN UND METHODEN, DIE ZU ALLEN ZEITEN (IN UND AUSSERHALB VON WETTKÄMPFEN) VERBOTEN SIND
Welt Anti-Doping Code
VERBOTSLISTE 2014
INTERNATIONALER
STANDARD
Fassung 2.0 (geänderte Fassung 2014)
Der offizielle Wortlaut der Verbotsliste wird von der WADA geführt und in englischer und
französischer Sprache veröffentlicht. Bei Unstimmigkeiten zwischen der englischen und
französischen Fassung ist die englische Fassung maßgebend.
Diese Liste tritt am 1. September 2014 in Kraft
VERBOTENE SUBSTANZEN
S0. NICHT ZUGELASSENE SUBSTANZEN
Pharmakologisch wirksame Substanzen, die in den folgenden Abschnitten der Verbotsliste
nicht aufgeführt und derzeit nicht durch eine staatliche Gesundheitsbehörde für die therapeutische Anwendung beim Menschen zugelassen sind (zum Beispiel Arzneimittel in der
präklinischen oder klinischen Entwicklung bzw. Arzneimittel, deren Entwicklung eingestellt
wurde, Designerdrogen, nur für die Anwendung bei Tieren zugelassene Substanzen), sind zu
jeder Zeit verboten.
S1. ANABOLE SUBSTANZEN
Anabole Substanzen sind verboten.
1. Anabol-androgene Steroide (AAS)
a. Exogene* AAS, einschließlich
1-Androstendiol (5alpha-Androst-1-en-3beta,17beta-diol); 1-Androstendion (5alpha-Androst-1-en-3,17-dion); Bolandiol (Estr-4-en-3beta,17beta-diol); Bolasteron; Boldenon;
Boldion (Androsta-1,4-dien-3,17-dion); Calusteron; Clostebol; Danazol
([1,2]Oxazolo[4',5':2,3]pregna-4-en-20-yn-17alpha-ol); Dehydrochlormethyltestosteron (4Chlor-17beta-hydroxy-17alpha-methylandrosta-1,4-dien-3-on); Desoxymethyltestosteron
(17alpha-Methyl-5alpha-androst-2-en-17beta-ol); Drostanolon; Ethylestrenol (19-Norpregna-4-en-17alpha-ol); Fluoxymesteron; Formebolon; Furazabol (17alphaMethyl[1,2,5]oxadiazolo[3',4':2,3]-5alpha-androstan-17beta-ol); Gestrinon; 4-Hydroxytestosteron (4,17beta-Dihydroxyandrost-4-en-3-on); Mestanolon; Mesterolon; Metandienon
(17beta-Hydroxy-17alpha-methylandrosta-1,4-dien-3-on); Metenolon; Methandriol;
Methasteron (17beta-Hydroxy-2alpha,17alpha-dimethyl-5alpha-androstan-3-on); Methyldienolon (17beta-Hydroxy-17alpha-methylestra-4,9-dien-3-on); Methyl-1-testosteron
(17beta-Hydroxy-17alpha-methyl-5alpha-androst-1-en-3-on); Methylnortestosteron
(17beta-Hydroxy-17alpha-methylestr-4-en-3-on); Methyltestosteron; Metribolon
Verbotsliste der WADA 2014
Informatorische Übersetzung der NADA – Nationale Anti Doping Agentur für Deutschland
2
(Methyltrienolon, 17beta-Hydroxy-17alpha-methylestra-4,9,11-trien-3-on); Miboleron;
Nandrolon; 19-Norandrostendion (Estr-4-en-3,17-dion); Norbolethon1; Norclostebol;
Norethandrolon; Oxabolon; Oxandrolon; Oxymesteron; Oxymetholon; Prostanozol (17beta[(Tetrahydropyran-2-yl)oxy]-1'H-pyrazolo[3,4:2,3]-5alpha-androstan); Quinbolon; Stanozolol;
Stenbolon; 1-Testosteron (17beta-hydroxy-5alpha-androst-1-en-3-on);
Tetrahydrogestrinon (17-Hydroxy-18a-homo-19-nor-17alpha-pregna-4,9,11-trien-3-on);
Trenbolon (17beta-Hydroxyestr-4,9,11-trien-3-on); und andere Substanzen mit ähnlicher
chemischer Struktur oder ähnlicher/n biologischer/n Wirkung(en).
b. Endogene** AAS bei exogener Verabreichung:
Androstendiol (Androst-5-en-3beta,17beta-diol); Androstendion (Androst-4-en-3,17-dion);
Dihydrotestosteron (17beta-Hydroxy-5alpha-androstan-3-on)2; Prasteron (Dehydroepiandrosteron, DHEA, 3beta-Hydroxyandrost-5-en-17-on); Testosteron und ihre Metaboliten
und Isomere, darunter unter anderen:
5alpha-Androstan-3alpha,17alpha-diol; 5alpha-Androstan-3alpha,17beta-diol; 5alpha-Androstan-3beta,17alpha-diol;
5alpha-Androstan-3beta,17beta-diol;
Androst-4-en3alpha,17alpha-diol; Androst-4-en-3alpha,17beta-diol; Androst-4-en-3beta,17alpha-diol;
Androst-5-en-3alpha,17alpha-diol;
Androst-5-en-3alpha,17beta-diol;
Androst-5-en3beta,17alpha-diol; 4-Androstendiol (Androst-4-en-3beta,17beta-diol); 5-Androstendion
(Androst-5-en-3,17-dion); Epidihydrotestosteron; Epitestosteron; Etiocholanolon; 3alphaHydroxy-5alpha-androstan-17-on;
3beta-Hydroxy-5alpha-androstan-17-on;
7alphaHydroxy-DHEA; 7beta-Hydroxy-DHEA; 7-Keto-DHEA; 19-Norandrosteron; 19-Noretiocholanolon.
2. Zu den anderen anabolen Substanzen gehören unter anderem
Clenbuterol, Selektive Androgen-Rezeptor-Modulatoren (SARMs), Tibolon, Zeranol,
Zilpaterol.
* Für die Zwecke dieses Abschnitts bezieht sich der Begriff „exogen“ auf eine Substanz, die vom Körper normalerweise nicht auf natürlichem Wege produziert wird.
** Für die Zwecke dieses Abschnittes bezieht sich der Begriff „endogen“ auf eine Substanz, die vom
Körper normalerweise auf natürlichem Wege produziert wird.
S2. PEPTIDHORMONE, WACHSTUMSFAKTOREN UND VERWANDTE SUBSTANZEN
1. Erythropoese-stimulierende Stoffe [zum Beispiel Erythropoetin (EPO), Darbepoetin
(dEPO), Hypoxie-induzierbarer-Faktor (HIF)-Stabilisatoren und –Aktivatoren (z.B.
Xenon, Argon), Methoxy-Polyethylenglycol-Epoetin beta (CERA – Continuous
Erythropoiesis Receptor Activator), Peginesatide (Hematide)];
Luteinisierendes
Hormon
(LH)
und
ihre
2
und andere Substanzen mit ähnlicher chemischer Struktur oder ähnlicher/n biologischer/n
Wirkung(en).
S3. Β-2-AGONISTEN
Alle Beta-2-Agonisten, gegebenenfalls auch alle optischen Isomere (z. B. D- und L-), sind
verboten; hiervon ausgenommen sind inhaliertes Salbutamol (höchstens 1.600 Mikrogramm
über 24 Stunden), inhaliertes Formoterol (abgegebene Dosis höchstens 54 Mikrogramm über
24 Stunden) und Salmeterol, wenn es entsprechend den therapeutischen Empfehlungen der
Hersteller inhaliert wird.
Ein Salbutamolwert im Urin von mehr als 1.000 Nanogramm/ml oder ein Formoterolwert von
mehr als 40 Nanogramm/ml wird nicht als beabsichtigte therapeutische Anwendung der
Substanz angesehen und gilt als ein von der Norm abweichendes Analyseergebnis, es sei
denn, der Athlet weist anhand einer kontrollierten pharmakokinetischen Studie nach, dass
dieses abnorme Ergebnis die Folge der Anwendung einer therapeutischen inhalatierten Dosis bis zu dem oben genannten Höchstwert war.
S4. HORMONE UND STOFFWECHSEL-MODULATOREN
Es gelten folgende Verbote:
1. Aromatasehemmer; dazu gehören unter anderem Aminoglutethimid, Anastrozol,
Androsta-1,4,6-trien-3,17-dion (Androstatriendion), 4-Androsten-3,6,17-trion (6oxo), Exemestan, Formestan, Letrozol, Testolacton.
3. Andere antiestrogene Substanzen; dazu gehören unter anderem Clomifen, Cyclofenil, Fulvestrant.
4. Substanzen, welche die Myostatinfunktion(en) verändern; dazu gehören unter anderem Myostatinhemmer.
5. Stoffwechselmodulatoren:
b) PPARδ (Peroxisome Proliferator Activated Receptor Delta)-Agonisten (z. B.
GW1516) und AMPK (PPARδ-AMP-activated protein kinase)-Achse-Agonisten (z.
B. AICAR).
Hinzufügung des Bundesinnenministeriums: Synonym (Freiname nach INN): Norboleton.
Hinzufügung des Bundesinnenministeriums: Synonym (Freiname nach INN): Androstanolon.
Fibroblasten-Wachstumsfaktoren (FGFs), Hepatozyten-Wachstumsfaktor (HGF),
mechanisch induzierte Wachstumsfaktoren (MGFs), Blutplättchen-Wachstumsfaktor (PDGF), vaskulär-endothelialer Wachstumsfaktor (VEGF) sowie alle anderen
Wachstumsfaktoren, die in Muskeln, Sehnen oder Bändern die Proteinsynthese/den
Proteinabbau, die Gefäßbildung/-versorgung, die Energieausnutzung, die Regenerationsfähigkeit oder die Umwandlung des Fasertyps beeinflussen;
a) Insuline
3. Corticotropine und ihre Releasingfaktoren;
1
Darüber hinaus sind die folgenden Wachstumsfaktoren verboten:
2. Selektive Estrogen-Rezeptor-Modulatoren (SERMs); dazu gehören unter anderem
Raloxifen, Tamoxifen, Toremifen.
Die folgenden Substanzen und andere Substanzen mit ähnlicher chemischer Struktur oder
ähnlicher/n biologischer/n Wirkung(en) sind verboten:
2. Choriongonadotropin (CG) und
Releasingfaktoren bei Männern;
4. Wachstumshormon (GH) und seine Releasingfaktoren, insulinähnlicher Wachstumsfaktor 1 (IGF-1).
3
4
VERBOTENE METHODEN
S5. DIURETIKA UND ANDERE MASKIERUNGSMITTEL
Maskierungsmittel sind verboten. Hierzu gehören:
Diuretika, Desmopressin, Plasmaexpander (zum Beispiel Glycerol; intravenös verabreichte(s) Albumin, Dextran, Hydroxyethylstärke und Mannitol), Probenecid
und andere Substanzen mit ähnlicher/n biologischer/n Wirkung(en).
M1. MANIPULATION VON BLUT UND BLUTBESTANDTEILEN
Folgende Methoden sind verboten:
1. Die Verabreichung oder Wiederzufuhr jeder Menge von autologem, allogenem (homologem) oder heterologem Blut oder Produkten aus roten Blutkörperchen jeglicher
Herkunft in das Kreislaufsystem.
Die lokale Verabreichung von Felypressin in der Dentalanästhesie ist nicht verboten.
Zu den Diuretika gehören
Acetazolamid, Amilorid, Bumetanid, Canrenon, Chlortalidon, Etacrynsäure, Furosemid,
Indapamid, Metolazon, Spironolacton, Thiazide (zum Beispiel Bendroflumethiazid,
Chlorothiazid, Hydrochlorothiazid), Triamteren, Vaptane (zum Beispiel Tolvaptan)
Wirkung(en) (ausgenommen Drospirenon, Pamabrom und topisches Dorzolamid und
Brinzolamid, die nicht verboten sind).
Für die Verwendung in und gegebenenfalls außerhalb von Wettkämpfen jeglicher Menge einer Substanz, die Grenzwerten unterliegt (das heißt Formoterol, Salbutamol, Cathin,
Ephedrin, Methylephedrin und Pseudoephedrin), in Verbindung mit einem Diuretikum oder
einem anderen Maskierungsmittel, muss neben der Medizinischen Ausnahmegenehmigung
für das Diuretikum oder ein anderes Maskierungsmittel auch eine gesonderte Medizinische
Ausnahmegenehmigung für diese Substanz vorgelegt werden.
2. Die künstliche Erhöhung der Aufnahme, des Transports oder der Abgabe von Sauerstoff, unter anderem durch Perfluorchemikalien, Efaproxiral (RSR 13) und veränderte
Hämoglobinprodukte (zum Beispiel Blutersatzstoffe auf Hämoglobinbasis, mikroverkapselte Hämoglobinprodukte), außer ergänzender Sauerstoff.
3. Jegliche Form der intravaskulären Manipulation von Blut oder Blutbestandteilen mit
physikalischen oder chemischen Mitteln.
M2. CHEMISCHE UND PHYSIKALISCHE MANIPULATION
Folgende Methoden sind verboten:
1. Die tatsächliche oder versuchte unzulässige Einflussnahme, um die Integrität und Validität der Proben, die während der Dopingkontrollen genommen werden, zu verändern. Hierunter fallen unter anderem der Austausch und/oder die Verfälschung (zum
Beispiel mit Proteasen) von Urin.
2. Intravenöse Infusionen und/oder Injektionen von mehr als 50 ml innerhalb eines Zeitraums von sechs Stunden, es sei denn, sie werden rechtmäßig im Zuge von Krankenhauseinweisungen oder klinischen Untersuchungen verabreicht.
M3. GENDOPING
Die folgenden Methoden zur möglichen Steigerung der sportlichen Leistung sind verboten:
1. Die Übertragung von Nukleinsäure-Polymeren oder Nukleinsäure-Analoga;
2. die Anwendung normaler oder genetisch veränderter Zellen.
5
6
IM WETTKAMPF VERBOTENE SUBSTANZEN UND
METHODEN
S7. NARKOTIKA
Die folgenden Narkotika sind verboten:
Zusätzlich zu den oben beschriebenen Kategorien S0 bis S5 und M1 bis M3 sind im
Wettkampf folgende Kategorien verboten:
VERBOTENE SUBSTANZEN
S8. CANNABINOIDE
S6. STIMULANZIEN
Alle Stimulanzien, gegebenenfalls auch alle optischen Isomere (z. B. D- und L-), sind verboten; hiervon ausgenommen sind Imidazolderivate für die topische Anwendung und die in das
Überwachungsprogramm für 2014* aufgenommenen Stimulanzien.
Zu den Stimulanzien gehören
a:
Buprenorphin, Dextromoramid, Diamorphin (Heroin), Fentanyl und seine Derivate,
Hydromorphon, Methadon, Morphin, Oxycodon, Oxymorphon, Pentazocin, Pethidin.
Nicht-spezifische Stimulanzien:
Adrafinil, Amfepramon, Amiphenazol, Amphetamin, Amphetaminil, Benfluorex, Benzylpiperazin, Bromantan, Clobenzorex, Cocain, Cropropamid, Crotetamid, Fencamin,
Fenetyllin, Fenfluramin, Fenproporex, Fonturacetam [4-Phenylpirazetam (Carphedon)],
Furfenorex, Mefenorex, Mephentermin, Mesocarb, Methamphetamin (D-), p-Methylamphetamin, Modafinil, Norfenfluramin, Phendimetrazin, Phenmetrazin, Phentermin,
Prenylamin, Prolintan.
Natürliches (z. B. Cannabis, Haschisch, Marihuana) oder synthetisches Delta-9-Tetrahydrocannabinol (THC) und Cannabinomimetika (z. B. „Spice“, JWH018, JWH073, HU-210) sind
verboten.
S9. GLUCOCORTICOSTEROIDE
Alle Glucocorticosteroide sind verboten, wenn sie oral, intravenös, intramuskulär oder rektal
verabreicht werden.
Stimulanzien, die in diesem Abschnitt nicht ausdrücklich genannt sind, gelten als spezifische
Substanzen.
b:
Spezifische Stimulanzien (Beispiele):
Benzphetamin, Cathin**, Cathinon und seine Analoga (zum Beispiel Mephedron,
Methedron,
alpha-Pyrrolidinovalerophenon),
Dimethylamphetamin,
Ephedrin***,
Epinephrin**** (Adrenalin), Etamivan, Etilamphetamin, Etilefrin, Famprofazon, Fenbutrazat,
Fencamfamin,
Heptaminol,
Hydroxyamphetamin
(Parahydroxyamphetamin),
Isomethepten, Levmetamphetamin, Meclofenoxat, Methylendioxymethamphetamin,
Methylephedrin***, Methylhexanamin (Dimethylpentylamin), Methylphenidat, Nicethamid,
Norfenefrin, Octopamin, Oxilofrin (Methylsynephrin), Pemolin, Pentetrazol, Phenpromethamin, Propylhexedrin, Pseudoephedrin*****, Selegilin, Sibutramin, Strychnin,
Tenamphetamin (Methylendioxyamphetamin), Trimetazidin, Tuaminoheptan
Wirkung(en).
*
**
***
****
*****
Die folgenden in das Überwachungsprogramm für 2014 aufgenommenen Substanzen (Bupropion,
Koffein, Nikotin, Phenylephrin, Phenylpropanolamin, Pipradol, Synephrin) gelten nicht als verbote
ne Substanzen.
Cathin ist verboten, wenn seine Konzentration im Urin 5 Mikrogramm/ml übersteigt.
Sowohl Ephedrin als auch Methylephedrin sind verboten, wenn ihre Konzentration im Urin jeweils 10 Mikrogramm/ml übersteigt.
Die lokale Anwendung (zum Beispiel nasal, ophthalmologisch) von Epinephrin (Adrenalin) oder
die Verabreichung in Verbindung mit einem Lokalanästhetikum ist nicht verboten.
Pseudoephedrin ist verboten, wenn seine Konzentration im Urin 150 Mikrogramm/ml übersteigt.
7
8
IN BESTIMMTEN SPORTARTEN VERBOTENE
SUBSTANZEN
P1. ALKOHOL
Alkohol (Ethanol) ist in den nachfolgenden Sportarten nur im Wettkampf verboten. Die Feststellung erfolgt durch Atem- oder Blutanalyse. Der Grenzwert, ab dem ein Dopingverstoß
vorliegt, entspricht einer Blutalkoholkonzentration von 0,10 g/l.
Bogenschießen (WA)
Karate (WKF)
Luftsport (FAI)
Motorbootsport (UIM)
Motorradsport (FIM)
Motorsport (FIA)
P2. BETABLOCKER
Wenn nichts anderes bestimmt ist, sind Betablocker in den folgenden Sportarten nur im
Wettkampf verboten:
Billard (alle Disziplinen) (WCBS)
Bogenschießen (WA) (auch außerhalb von Wettkämpfen verboten)
Darts (WDF)
Golf (IGF)
Motorsport (FIA)
Schießen (ISSF, IPC) (auch außerhalb von Wettkämpfen verboten)
Skifahren/Snowboarding (FIS) im Skispringen, Freistil aerials/halfpipe und
Snowboard halfpipe/big air
Zu den Betablockern gehören unter anderem
Acebutolol, Alprenolol, Atenolol, Betaxolol, Bisoprolol, Bunolol, Carteolol, Carvedilol,
Celiprolol, Esmolol, Labetalol, Levobunolol, Metipranolol, Metoprolol, Nadolol, Oxprenolol, Pindolol, Propranolol, Sotalol, Timolol.
9

5. Mitteldeutscher Schmerztag 2014

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