Ibuprofen and Its Effects During Ultramarathons

ibuprofenMany runners use anti-inflammatory medications (ibuprofen or Motrin, also known as NSAIDs) before, during, and after running to stave off pain. I personally have had mixed results using these medications while running, and do remember quite vividly having intense back pain after Squaw Peak 50 mile race in June of 2001 where I used ibuprofen throughout the race. I didn’t use ibuprofen much during runs after that, and after seeing what happened to Erik Skaggs at Where’s Waldo 100k last year[1], I decided to dig a little deeper into the subject and do some research. It’s a tough subject to gather information on because not a lot of medical research has been focused in this area. Most medical research focuses on “already sick” people and not healthy athletes. There is one specific event, however, where quite a lot of research material was put together from information gathered at Western States 100 in 2005.

Three journal articles were written using the data gathered at Western States 100 mile endurance run. In the studies analyzed, both male and female athletes were selected (54 total athletes):  29 were placed in the ibuprofen group, while 25 were placed in the control (non-ibuprofen) group. Blood and urine samples were collected from participants in both groups before and after the race. In the ibuprofen group, participants ingested 600mg day before race, and 1200mg (divided into doses of 200mg every 4 hours) on race day.

McAunulty Study
In a study by Steven McAunulty, et al.[2], the authors looked at how oxidative stress on the body was influenced by ibuprofen use. Oxidative stress, for clarification, is the inability to detoxify and repair damage to body systems done by the production of free radicals and peroxides. Free radicals and peroxides can cause direct damage to cells and can disrupt normal energy production within cells. When overly abundant, they can cause cell death.

McAnulty looked at certain measurable inflammatory markers (F2-isoprostanes) in the blood and urine and when comparing pre-race to post-race samples, found significantly differing levels of inflammatory makers in both blood and urine in the post-race ibuprofen-use samples. His conclusion was, “Ibuprofen use compared with nonuse by athletes competing in a 160-km race was associated with significantly increased oxidative stress.”

How does this happen and what does it mean?

  1. Kidney cells may be damaged and altered during and ultramarathon as a result of ibuprofen use. There has been previous research that has shown that ibuprofen increases blood flow to the stomach and small intestine and thereby increases leakage of toxins into the bloodstream, increasing oxidative stress. Ultrarunning magnifies this effect.
  2. Post-race blood levels of measured inflammatory markers (F2-isoprostanes) were elevated by 37% above normal in the ibuprofen group, compared to 20% elevation in the non-ibuprofen group. These same markers, when measured in post-race urine, were increased by 138% in the ibuprofen users, and unchanged in non-users. This is statistically significant data that shows ibuprofen was increasing stress on body.
  3. The authors concluded that based on their findings, “we recommend caution in using ibuprofen and other NSAIDs during ultra-distance exercise events.”

Nieman Study
David Nieman, et al.[3] used the same study subjects and samples to analyze a different set of inflammatory markers. I think the most interesting thing that he did was to also set up a subjective pain-rating score for the athletes to use. The 10-point Likert scale for measuring delayed onset muscle soreness (DOMS) was used for the seven days following race completion.

Statistically significant was the following study conclusion, “Ibuprofen use compared to non-use by athletes competing in a 160-km race did not alter muscle damage or soreness, and was related to elevated indicators of endotoxemia and inflammation.” The measured damage was seen in decreased capability of the kidneys to filter toxins properly (by measuring decreased urine creatinine, a typical test used to measure kidney function), and higher levels of blood inflammatory markers (interleukins, cytokines, and c-reactive protein:  all indicators of inflammation and pain).

Dumke Study
Charles L. Dumke, et al.[4] likewise analyzed information gathered from Western States 2005. Previous data collected in other studies measured significant electrolyte disturbances while running and using ibuprofen. Dumke dispelled this information. Ibuprofen use did not, in and of itself, alter blood concentrations of key electrolytes such as sodium, potassium, chloride, or calcium, nor did it affect blood proteins. An interesting trend was discovered, however:  longer running times, lower training volumes, and older runner age all correlated with lower sodium concentrations (hyponatremia) at the finish line, suggesting that the longer you are out there and the older you are, the more important it is to pay attention to electrolyte replacement.

Take Home Information:
The studies results in a lot of daunting scientific speak. I did my best to pare it down to an understandable discussion. I think there is some really valuable information to be gained from these articles, and I look forward to more studies being conducted in the future. Probably the most important point that is not discussed in these journal articles is the fact of listening to our bodies, and doing what we feel is right for them. As tough as we may be as ultrarunners, it is always good to hold a healthy dose of respect for the fragility of the human body. What has worked for us in the past may not work for us in the future, and something that we have never used before may just be the magic ticket to get us through our next race.

Missy Berkel is a Nurse Practitioner from Salt Lake City, Utah and has been running ultras since 1998.  She is running the Wasatch 100 in September.

[1] http://runtrails.blogspot.com/2009/08/erik-skaggs-hospitalized-for-renal.html

[2] McAnulty, et al. (2007). Ibuprofen use during extreme exercise:  effects on oxidative stress and PGE2. Medicine and Science in Sports and Exercise (39)7.

[3] Nieman, et al. (2006). Ibuprofen use, endotoxemia, inflammation, and plasma cytokines during ultramarathon competition. Brain, Behavior, and Immunity 20.

[4] Dumke, et al. (2007). Ibuprofen does not affect serum electrolyte concentrations after an ultradistance run. British Journal of Sports Medicine 41.