This Sunday, more than 50,000 people will take part in the London Marathon; that’s just over 42 kilometers of blood, sweat and tears – and then adrenaline, as the runners cross the finish line.
They will end the day with lifelong memories, raise millions for charity and, crucially, get a huge health boost from the months of training.
While the benefits of running far outweigh the disadvantages if you are otherwise healthy, there are risks: some may not finish the race and may end up with a serious medical emergency.
Many of you reading this will never make it through and may think that none of this is relevant to you.
Professor Rob Galloway has been medical director of the Brighton Marathon for twelve years
But if you’re taking anti-inflammatory tablets like ibuprofen or using a pain-relieving anti-inflammatory gel, think again.
Let me explain: two weeks ago it was the Brighton Marathon, where I have been medical director for the past twelve years. I’ve seen the problems a huge run can cause, and this year was no exception.
As I write this, one of our runners is still in hospital due to heat stroke and kidney failure; his life was saved by the medical team on the course.
In his twenties, he was just nearing the end of the race when he collapsed. His temperature was over 41 degrees Celsius and we used a specially designed cooling capsule (I-CWIK) developed by the military. This young man is now on dialysis because running this race damaged his kidneys so severely.
Heatstroke and kidney failure may have claimed the life of the legendary Greek soldier Pheidippides in 490 BC. – after running from Marathon to Greece to declare ‘Victory’, he fell dead (his feat was commemorated in the first marathon of the 1896 Greek Olympics) .
While we don’t fully understand the complexities of these two circumstances, something the Brighton marathoner told me has implications not just for next Sunday’s runners, but for all of us. (And helps explain why this otherwise fit and healthy man became so dangerously ill).
The day after his run, he said that to avoid knee pain during the marathon, he took an ibuprofen tablet just in case.
Marathon runners should be careful about taking anti-inflammatories such as Nurofen, says Prof. Rob
Anti-inflammatory tablets such as ibuprofen, naproxen and even gels such as Voltarol are types of NSAIDs – non-steroidal anti-inflammatory drugs. They work by inhibiting an enzyme called cyclooxygenase (COX), which is involved in inflammation.
During strenuous physical activity and in hot weather, the body loses its ability to regulate temperature (partly due to increased heat production from the muscles working so hard; while dehydration and blood flow shunted from the skin to vital organs that you sweat less).
NSAIDs make this worse in a number of ways, including reducing the kidneys’ ability to control fluid balance in the blood. But not everyone is affected in the same way.
In a study published late last year in the Journal of Science and Medicine in Sport, we gave runners small thermometers that they swallowed before the race: the results showed that some runners who experienced temperatures above 40 degrees Celsius had no symptoms while others suffered from it. heat stroke (with symptoms such as confusion, muscle stiffness and kidney failure).
So something other than body temperature was at play that caused them to collapse. One theory is that heat – from hot weather or strenuous exercise – causes bacteria to seep out of the intestines. NSAIDs – even a single tablet according to our Brighton runner – can also make our guts leakier. The bacteria enter the bloodstream and can cause symptoms similar to sepsis: low blood pressure, confusion and high heart rate.
In addition, some people experience increased muscle damage after running, which produces a protein in the blood – creatine kinase – that causes the kidneys to stop working. And yes, NSAIDs also reduce blood flow to the kidneys. A perfect storm for kidney failure.
This also contains an important message for non-runners.
A few years ago, a 58-year-old carpet fitter came to the emergency room lethargic, with poor concentration and itching. Blood tests showed that he urgently needed kidney dialysis.
And after examination, the cause became clear: he had developed knee pain after years of kneeling. As a self-employed person, he could not afford a day off, so he took ibuprofen every day and used Voltarol gel liberally. His long-term use of NSAIDs had caused kidney failure.
While the dialysis machine took over the function of his failing kidneys, stopping the anti-inflammatory drugs allowed his kidneys to heal and so he was able to leave the hospital two weeks later and was off dialysis. But it had been a close shave.
During strenuous physical activity and in hot weather, the body loses its ability to regulate temperature
When marathon running, are it only the tablets that are dangerous or do the gels also pose a risk? The answer is: we don’t know for sure: we know that gel is absorbed into the blood and so could theoretically cause problems, especially if used excessively.
This is why runners for the Brighton Marathon (now organized by London Marathon Events) were given specific medical advice before the race stating: ‘Do not take anti-inflammatory medicines before, during or for 24 hours after the marathon. . . Anti-inflammatory gels are safer than tablets but can also cause problems during marathon running so avoid them before or during the event.’
Unfortunately, most people do not read the advice sent and get advice from friends or social media.
It’s not just a one-off endurance exercise that’s a concern: using it over an extended period of time, no matter who you are, is a risk.
This includes both gels and tablets. Indeed, Voltarol gel states in the product information that it should not be used for more than 14 days unless otherwise prescribed by a doctor.
Although most people are aware of the risks of long-term use of NSAIDs in terms of intestinal problems such as bleeding, many may not be aware of the risks of kidney problems and heat stroke.
So when it comes to summer, it’s so important to avoid long-term use of these medications — and to avoid heatstroke, especially if you’re older, because worse kidney function as you age puts you at greater risk.
This, combined with the warning that NSAIDs are linked to a greater risk of heart attack, heart failure and stroke (inhibiting inflammation also leads to water and salt retention and higher blood pressure), is why I now advise my patients to take only for a short period.
If I’m going on a long run myself, I avoid any form of NSAID, even as a single dose.
And for people with chronic pain, such as arthritis, my advice is to seek other forms of relief, such as heat-like gels, cold water swimming and paracetamol.
We are over-medicalized when it comes to dealing with pain and we don’t always think about the side effects of medications.
NSAIDs can provide temporary relief, but they can be very risky in the long term.
As for runners, a one-time dose of NSAID before a race can help you reach the starting line, but they can risk you reaching the finish line safely.
As my patient told me as I left the intensive care bed, “I had no idea that my ibuprofen tablet could be causing my problems. Please tell others so they know and don’t suffer like I did.’
@drrobgalloway