Celecoxib for sporting injuries - Australian Sports Commission

Introduction
Celecoxib for sporting injuries: Tolerability and side effects
A.B. Johnston* Western Australia
Non-steroidal anti-inflammatory drugs (NSAIDs) are widely used in the treatment of sporting injuries. Inflammation occurs at the site of injury.
A local soft tissue injury causes the release of arachidonic acid from cell walls. Arachidonic acid is converted by a number of enzymes, in
particular cyclo-oxygenase(COX), to prostaglandins, thromboxane and prostacyclins. NSAIDs have been shown to interfere with the conversion
of arachidonic acid to prostaglandin by inhibiting the action of COX. NSAIDs may also have other effects on the inflammatory response.
Although NSAIDs are effective for the relief of pain and inflammation, their use is tempered by the development of side effects, primarily
gastrointestinal.
Cyclo-oxygenase exists as at least two isoenzymes, COX-1 and COX-2. COX-1, a wide-ranging essential enzyme, produces prostaglandins
involved in cytoprotective and regulatory functions in gastrointestinal mucosa, platelets, and renal cells; gastric prostaglandins are derived
almost exclusively from COX-1. COX-2, predominantly a cytokine-induced enzyme, produces prostaglandins that mediate pain and inflammation.
All NSAIDs inhibit COX-1 and COX-2, each to varying degrees. The therapeutic effects of NSAIDs are achieved by COX-2 inhibition, but many
of the toxic effects, most commonly gastroduodenal injury, result from COX-1 inhibition. Celecoxib was designed to specifically inhibit COX-2.
Clinical trials have demonstrated that celecoxib is as effective in ameliorating signs and symptoms of osteoarthritis and rheumatoid arthritis
as conventional NSAIDs, and as effective as aspirin in reducing pain following dental extraction. Controlled trials have also shown that the
incidence of gastroduodenal ulcers and erosions are significantly lower with celecoxib than with conventional NSAIDs.
There are no published data on the use of celecoxib for acute sporting injuries. With conventional NSAIDs, there is no convincing evidence
as to their effectiveness in the treatment of acute soft tissue injuries. Numerous studies have been done but most lacked a placebo group and
compared the effectiveness on one NSAID with another.
At a local Perth football club, short courses of NSAIDs are routinely used in the treatment of acute soft tissue injuries. Side effects, usually
gastrointestinal, do occur. The incidence of peptic ulceration with the short term use of NSAIDs is rare in the athletic population. Players are
highly motivated to recover from injuries and sometimes this leads them to take high doses of NSAIDs. An effective NSAID with a better safety
profile would be welcomed. This study will look at the tolerability, side effects and efficacy of celecoxib in the treatment of acute sporting
injuries.
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Methods
Celecoxib for sporting injuries: Tolerability and side effects
A.B. Johnston* Western Australia
Study population: Males playing semi-professional Australian Rules football at a local Perth football club. Aged between 18 and 30 years.
Those sustaining a soft tissues injury from their sport, and requiring treatment.
Exclusions: Aged under 18 or over 30 years. Aspirin sensitive asthma. Allergy to aspirin or NSAIDs. Allergy to sulfur. Those requiring an
injection of corticosteroid or anaesthetic during the course of the study. Those on continuous NSAIDs or corticosteroid medication. Any player
who has been included in the study and has a further injury, will also be excluded.
Treatment: Players injured during competition or training are assessed by the club doctor. If an acute soft tissue injury that would benefit from
an NSAID, player invited to trial celecoxib. Medication to be started within 24 hours of injury. Informed consent given. Player is given a three
day supply of celecoxib with instructions to attend medical staff for review. At the three day check, if the injury has resolved, celecoxib is
stopped. Otherwise a further three days supply of celecoxib is given. After 6 days, the player is reviewed again by the club doctor. The club
nurse then assesses tolerability, side effects, and efficacy of treatment. Through direct questioning, the nurse asks the player about any side
effects. Pain relief is assessed on a visual scale of 0 to 5. The nurse asks players if any tablets are left, to check compliance.
There was no randomisation of players into the study. No placebo and no rescue analgesic medication was offered. Although celecoxib is
usually taken twice daily, to aid compliance a daily dose of 400mg once a day was used.
Results
Forty one players completed the study. One player with mild asthma chose not to enter the study as he was concerned about asprin sensitive
asthma. (He had taken ibuprofen the previous year with no problem). Another player was excluded when his injury to the forearm turned out
to be a fracture.
The average age of the players was 21 years, the average weight was 80 kg. The lower limb was the commonest site of injury (68%), followed
by the upperlimb (15%) and trunk (17%). The type of injury was muscle or tendon in 23 (56%) cases, and joint in 18 (44%) cases. An
aggravation of a previous injury was seen in 7 (17%) players, with 34 (83%) sustaining a new injury. No serious injuries requiring surgery were
recorded.
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Celecoxib for sporting injuries: Tolerability and side effects
A.B. Johnston* Western Australia
Thirty nine players (95%) completed the course of celecoxib, two players stopped after 3 days due to side effects. Diarrhoea occurred in one
(2.4%), and an upper respiratory tract infection in another (2.4%). One player who couldn’t tolerate conventional NSAIDs due to dyspepsia,
had no side effects from six days of celecoxib.
Sixteen players (34%) received a three day course of celecoxib, 25 (61%) having a six day course. For pain relief, 30 (73%) players rated
celecoxib as providing good, or very good cover; with 3 (7.3%) players stating they got little or no pain relief. Seven players (17%) stated the
pain relief lasted for 24 hours or more, 34 (83%) having pain relief that didn’t last 24 hours.
Discussion
In this study, fit young adult males were offered celecoxib as part of their injury treatment. There were highly motivated to return to match
fitness. Enthusiastic medical staff followed them up. Leading questions were asked about their response to treatment. There was no
randomisation of players into the celecoxib study. There was no placebo group. Players play football because they love playing. If they miss
a game they also miss out on match payments. Discussions with treatment staff and players indicated that if a placebo was offered to the
player, this could potentially risk them missing a game needlessly, and would be rejected outright by the player. No rescue analgesic medication
was offered to the players. The numbers in this study is small, and the number of adverse effects was low. The incidence of side effects from
a short course of celecoxib was diarrhoea in 2.4%, and upper respiratory tract infection 2.4%. This compares favourably with published studies
of side effects of celecoxib: diarrhoea 5%, upper respiratory infection 7%.
Although celecoxib appeared to give good to very good pain relief in 73% of players, for the above reasons this can’t be scientifically proven.
It might only be as effective as paracetamol. More studies need to be done.
For these players who self medicate with super high doses of NSAIDs in the belief they will recover faster, celecoxib would have a place in
reducing the risk of gastroduodenal injury.
It is the intention of the author to increase the sample size of the study to 50, reanalyse the results, and then approach a pharmaceutical
company to determine their interest in sponsoring a large scientific study into celecoxib and its benefits for acute sporting injuries.
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Conclusion
Celecoxib for sporting injuries: Tolerability and side effects
A.B. Johnston* Western Australia
Finding the best and safest treatment for sporting injuries is important. Celecoxib appears to help relieve pain, and is well tolerated. Randomised
placebo controlled, scientific studies are needed to determine the place of NSAIDs in treating sporting injuries.
References
Bruckner, Khan. Clinical sports medicine. McGraw-Hill, 1993; 107
Almekinders LC. Anti-inflammatory treatment of muscular injuries in sport. An update of recent studies. Sports Med 1999; 28(6): 383-8.
Hertel J. The role of nonsteroidal anti-inflammatory drugs in the treatment of acute soft tissue injuries.
J Athletic Training 1997; 32(4): 350-358.
Smyth M. After an injury, what next? Aust Fam Physician 1999; 28: 555-560
Geis GS. Update on clinical developments with celecoxib, a new specific COX-2 inhibitor: what can we expect? Scand J Rheumatol 1999; 28
(Suppl 109): 31-7.
Bensen WG; Fiechtner JJ: McMillen JI, et al. Treatment of osteoarthritis with celecoxib, a cyclooxygenase-2 inhibitor: A randomised controlled
trial. Mayo Clin proc 1999;74: 1095-1105
Hawkey CJ. Cox-2 inhibitors. Lancet 1999; 353:307-314
Brooks PM, Day RO. Cox-2 inhibitors. Med J Aust. 2000; 173: 433-436
Print
Index
Table of Contents
Quit

Celecoxib for sporting injuries: Tolerability and side effects
A.B. Johnston*
Western Australia
INTRODUCTION: Non-steroidal anti-inflammatory drugs (NSAIDs) are widely used in the treatment of sporting injuries. Inflammation
occurs at the site of injury. A local soft tissue injury causes the release of arachidonic acid from cell walls. Arachidonic acid is converted by
a number of enzymes, in particular cyclo-oxygenase(COX), to prostaglandins, thromboxane and prostacyclins. NSAIDs have been
shown to interfere with the conversion of arachidonic acid to prostaglandin by inhibiting the action of COX. NSAIDs may also have other
effects on the inflammatory response. Although NSAIDs are effective for the relief of pain and inflammation, their use is tempered by the
development of side effects, primarily gastrointestinal.
Cyclo-oxygenase exists as at least two isoenzymes, COX-1 and COX-2. COX-1, a wide-ranging essential enzyme, produces
prostaglandins involved in cytoprotective and regulatory functions in gastrointestinal mucosa, platelets, and renal cells; gastric
prostaglandins are derived almost exclusively from COX-1. COX-2, predominantly a cytokine-induced enzyme, produces prostaglandins
that mediate pain and inflammation.
All NSAIDs inhibit COX-1 and COX-2, each to varying degrees. The therapeutic effects of NSAIDs are achieved by COX-2
inhibition, but many of the toxic effects, most commonly gastroduodenal injury, result from COX-1 inhibition. Celecoxib was designed to
specifically inhibit COX-2. Clinical trials have demonstrated that celecoxib is as effective in ameliorating signs and symptoms of
osteoarthritis and rheumatoid arthritis as conventional NSAIDs, and as effective as aspirin in reducing pain following dental extraction.
Controlled trials have also shown that the incidence of gastroduodenal ulcers and erosions are significantly lower with celecoxib than with
conventional NSAIDs.
There are no published data on the use of celecoxib for acute sporting injuries. With conventional NSAIDs, there is no convincing
evidence as to their effectiveness in the treatment of acute soft tissue injuries. Numerous studies have been done but most lacked a
placebo group and compared the effectiveness on one NSAID with another.
At a local Perth football club, short courses of NSAIDs are routinely used in the treatment of acute soft tissue injuries. Side effects,
usually gastrointestinal, do occur. The incidence of peptic ulceration with the short term use of NSAIDs is rare in the athletic population.
Players are highly motivated to recover from injuries and sometimes this leads them to take high doses of NSAIDs. An effective NSAID
with a better safety profile would be welcomed. This study will look at the tolerability, side effects and efficacy of celecoxib in the treatment of
acute sporting injuries.
METHODS: Study population: Males playing semi-professional Australian Rules football at a local Perth football club. Aged between
18 and 30 years. Those sustaining a soft tissues injury from their sport, and requiring treatment.
Exclusions: Aged under 18 or over 30 years. Aspirin sensitive asthma. Allergy to aspirin or NSAIDs. Allergy to sulfur. Those
requiring an injection of corticosteroid or anaesthetic during the course of the study. Those on continuous NSAIDs or corticosteroid
medication. Any player who has been included in the study and has a further injury, will also be excluded.
Treatment: Players injured during competition or training are assessed by the club doctor. If an acute soft tissue injury that would
benefit from an NSAID, player invited to trial celecoxib. Medication to be started within 24 hours of injury. Informed consent given. Player
is given a three day supply of celecoxib with instructions to attend medical staff for review. At the three day check, if the injury has
resolved, celecoxib is stopped. Otherwise a further three days supply of celecoxib is given. After 6 days, the player is reviewed again by
the club doctor. The club nurse then assesses tolerability, side effects, and efficacy of treatment. Through direct questioning, the nurse
asks the player about any side effects. Pain relief is assessed on a visual scale of 0 to 5. The nurse asks players if any tablets are left, to
check compliance.
There was no randomisation of players into the study. No placebo and no rescue analgesic medication was offered. Although
celecoxib is usually taken twice daily, to aid compliance a daily dose of 400mg once a day was used.
RESULTS: Forty one players completed the study. One player with mild asthma chose not to enter the study as he was concerned
about asprin sensitive asthma. (He had taken ibuprofen the previous year with no problem). Another player was excluded when his
injury to the forearm turned out to be a fracture.
The average age of the players was 21 years, the average weight was 80 kg. The lower limb was the commonest site of injury
(68%), followed by the upperlimb (15%) and trunk (17%). The type of injury was muscle or tendon in 23 (56%) cases, and joint in 18
(44%) cases. An aggravation of a previous injury was seen in 7 (17%) players, with 34 (83%) sustaining a new injury. No serious
injuries requiring surgery were recorded.
Thirty nine players (95%) completed the course of celecoxib, two players stopped after 3 days due to side effects. Diarrhoea
occurred in one (2.4%), and an upper respiratory tract infection in another (2.4%). One player who couldn't tolerate conventional
NSAIDs due to dyspepsia, had no side effects from six days of celecoxib.

Sixteen players (34%) received a three day course of celecoxib, 25 (61%) having a six day course. For pain relief, 30 (73%)
players rated celecoxib as providing good, or very good cover; with 3 (7.3%) players stating they got little or no pain relief. Seven
players (17%) stated the pain relief lasted for 24 hours or more, 34 (83%) having pain relief that didn't last 24 hours.
DISCUSSION: In this study, fit young adult males were offered celecoxib as part of their injury treatment. There were highly
motivated to return to match fitness. Enthusiastic medical staff followed them up. Leading questions were asked about their response to
treatment. There was no randomisation of players into the celecoxib study. There was no placebo group. Players play football because
they love playing. If they miss a game they also miss out on match payments. Discussions with treatment staff and players indicated that if
a placebo was offered to the player, this could potentially risk them missing a game needlessly, and would be rejected outright by the
player. No rescue analgesic medication was offered to the players. The numbers in this study is small, and the number of adverse effects
was low. The incidence of side effects from a short course of celecoxib was diarrhoea in 2.4%, and upper respiratory tract infection 2.4%.
This compares favourably with published studies of side effects of celecoxib: diarrhoea 5%, upper respiratory infection 7%.
Although celecoxib appeared to give good to very good pain relief in 73% of players, for the above reasons this can't be scientifically
proven. It might only be as effective as paracetamol. More studies need to be done.
For these players who self medicate with super high doses of NSAIDs in the belief they will recover faster, celecoxib would have a
place in reducing the risk of gastroduodenal injury.
It is the intention of the author to increase the sample size of the study to 50, reanalyse the results, and then approach a pharmaceutical
company to determine their interest in sponsoring a large scientific study into celecoxib and its benefits for acute sporting injuries.
CONCLUSION: Finding the best and safest treatment for sporting injuries is important. Celecoxib appears to help relieve pain, and is
well tolerated. Randomised placebo controlled, scientific studies are needed to determine the place of NSAIDs in treating sporting injuries.
REFERENCES:
1. Bruckner, Khan. Clinical sports medicine. McGraw-Hill, 1993; 107
2. Almekinders LC. Anti-inflammatory treatment of muscular injuries in sport. An update of recent studies. Sports Med 1999; 28(6):
383-8.
3. Hertel J. The role of nonsteroidal anti-inflammatory drugs in the treatment of acute soft tissue injuries.
4. J Athletic Training 1997; 32(4): 350-358.
5. Smyth M. After an injury, what next? Aust Fam Physician 1999; 28: 555-560
6. Geis GS. Update on clinical developments with celecoxib, a new specific COX-2 inhibitor: what can we expect? Scand J
Rheumatol 1999; 28 (Suppl 109): 31-7.
7. Bensen WG; Fiechtner JJ: McMillen JI, et al. Treatment of osteoarthritis with celecoxib, a cyclooxygenase-2 inhibitor: A
randomised controlled trial. Mayo Clin proc 1999;74: 1095-1105
8. Hawkey CJ. Cox-2 inhibitors. Lancet 1999; 353:307-314
9. Brooks PM, Day RO. Cox-2 inhibitors. Med J Aust. 2000; 173: 433-436