Non-Steroidal Anti-Inflammatory Drugs in Sports Medicine: Guidelines for Practical But Sensible Use (Editor's CHOICE‪)‬

Non-steroidal anti-inflammatory drugs (NSAID) are commonly utilised in sports medicine. NSAID have known anti-inflammatory, analgesic, anti pyretic and antithrombotic effects, (1) although their in-vivo effects in treating musculoskeletal injuries in humans remain largely unknown. NSAID analgesic action does not appear to be significantly greater than paracetamol for musculoskeletal injury (2) but they have a higher risk profile, with side-effects including asthma exacerbation, gastro intestinal and renal side-effects, hypertension and other cardiovascular diseases. Evidence-based working groups on pain management recommend using regular paracetamol as first-line treatment for acute (3) and chronic musculoskeletal pain. (4) Furthermore, intramuscular NSAID have addi tional risks with fluctuant drug levels, infection and muscle necrosis such as in Nicolau syndrome. (5) NSAID work via cyclooxygenase (COX) inhibi tion, thus blocking prostaglandin production from 35% arachadonic acid. Prostaglandin inhibition will decrease the cascading inflammatory response, but will also lead to increased leucotriene production through the "overflow" pathway for arachadonic acid.6 COX-2 inhibitors are a subclass of NSAID that specifically block the COX-2 enzyme, and subsequently have fewer gastrointestinal side-effects and renal side-effects but at a cost of an increased risk of cardiovascular side-effects. NSAID in sports medicine practice are delivered as topical, oral, intramuscular or, less commonly, intravenous preparations. Daily NSAID use in the general population is 1-4% (7,8) and in elite athletes at Olympic games or during Federation Internationale de Football Association World Cup football tourna ments, the reported use of NSAID is as high as 25-35% (9-11) Given their availability, the use of NSAID to treat sporting injury in the general population is probably similar to that seen in elite sporting populations. As medical practitioners, sports physi cians are obliged by the Hippocratic oath to "first do no harm", and this discussion paper will attempt to address the utilisation of NSAID use in musculoske letal injury pragmatically.