Page 111 - Athletic Health Handbook
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is yet to be proven primarily due metabolism, and excretion are all one death following an intramuscular
to the variety of NSAIDs studied affected by the intensity and duration injection of ketorolac.
as well as different dosing regimens. of exercise.9 During exercise, the
Animal studies have demonstrated rate of oral drug absorption usually Ketorolac is a reversible inhibitor of
that COX-2 inhibitors given after decreases, as blood supply to the GI platelet aggregation with a theoretical
acute injury are detrimental to tract is reduced. When prescribing increased bleeding risk, which could
tissue-level repair and cause impaired an NSAID in the athlete prior to limit its use in treating the injured
mechanical strength in bone, liga- or during athletic competition, the athlete. Singer et al33 determined the
ment, and tendon.13 Murnaghan physician must decide whether the effect of a single intramuscular dose of
et al10 reported impaired fracture benefits of prescribing an NSAID 60 mg on four-hour bleeding times in
healing with NSAID use and advo- outweigh the potential GI side effects healthy volunteers and found a mean
cated against using NSAID therapy due to dehydration and/or lack of prolongation of bleeding time of
following osseous injury. Mehallo food consumption. Data also indicate 1 minute 46 seconds. The clinical
et al8 suggested a 3- to 7-day course that adverse effects are more likely significance of this prolongation is
following muscle injury and recom- to occur during intense exercise of unclear, especially during exercise
mended avoiding NSAID use with longer duration.9 when blood flow increases during
chronic muscle injury. If the desired physical activity. Questions also
effects from a NSAID are not When treating athletes with remain regarding the drug’s safety
obtained after 10 to 14 days of COX-2 and COX-1 NSAIDs the when used in the athlete who resumes
therapy, a trial with an NSAID from concomitant use of other drugs must participation and sustains subcuta-
a different chemical classification be known so as to reduce undesirable neous or intramuscular trauma.
has also been recommended.14 or potentially lethal drug interactions.
NSAIDs may decrease the effective- Tokish et al34 investigated the use
NSAID Considerations in ness of diuretics, beta blockers, and of Torodol™ in the National Football
the Athletic Population angiotensin-converting enzyme League during the 2000 season. The
inhibitors. NSAIDs can increase the authors found that 93 percent of teams
The desired outcome when treating effectiveness of oral hypoglycemic used ketorolac and 93 percent used
an injured athlete is to relieve pain agents used to treat noninsulin- the medication on game day. Most
and enhance recovery; therefore, the dependent diabetes. Since many medical staffs noted that a single
analgesic effects of NSAIDs are often athletes self-medicate with over-the- injection alleviated 50 to 75 percent
beneficial. It is important to optimize counter NSAIDs, they should be of a player’s pain and lasted one to two
dose, dosing interval, and duration of cautioned not to take two NSAIDs days. Twenty-one percent of teams
therapy. The physician must consider simultaneously as the combination reported a mild adverse reaction;
the advantages of a longer duration will provide no additional therapeu- the most common were post-muscle
drug (naproxen; half-life t1/2 14 hours) tic benefit and may increase the risk soreness, isolated muscle injuries, and
versus a shorter duration drug of renal, cardiac, and GI toxicity.9 gastrointestinal disturbance. Although
(ibuprofen: half-life t1/2 6 hours). many medical staffs expressed
The peak blood level will rise until Ketorolac tromethamine concern regarding possible bleeding
the regular dosing has been given (Torodol™) is an injectable NSAID complications, none were reported.
beyond 5 half-lives of the drug. Thus, approved for up to five days of use for Currently, little published data exists
prescribing an NSAID with a shorter moderate to severe acute pain. Its peak regarding the efficacy and side effects
t1/2 could achieve a steady-state blood analgesic effect occurs within 30 to 60 of ketorolac use in athletes.
level and optimize analgesic and minutes of administration. Its analgesic
anti-inflammation effects sooner. efficacy has been extensively evaluated Can NSAIDs and
in the postoperative setting and has COX-2 Inhibitors Be
In athletes, the rate of NSAID been reported to produce relief from Administered Safely?
absorption from the small intestine moderate to severe pain. McAleer
into the blood must be considered. et al31 showed that ketorolac given in COX-2 use in patients with significant
Absorption of most orally adminis- single 15- and 30-mg intramuscular cardiovascular disease may increase
tered drugs occurs in the small doses was well tolerated with no the risk of an adverse cardiovascular
intestine, with the athlete’s hydration adverse events of gastrointestinal event. Several COX-1 NSAIDs
status impacting this absorption. etiology. Severe reactions can occur, (such as ibuprofen, diclofenac, and
The efficacy of drug absorption, however. Novembre et al32 reported indomethacin) and the COX-2
inhibitor, meloxicam (Mobic™),

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