Pharmacology in Athletic Training

SEATA Student Symposium 2012

Dr. Jason Bennett, DA, ATCChapman University

Where to Focus Your Attention When Preparing for the BOC

Exam?

Pass the BOC Exam !!

PharmacologyClass?

O & A Class ?

Gen Med Class?Clinical

Experience?

Patient Care

BOC Candidate Handbook for 2012-2013

% of Questions on Exam

Injury/Illness Prevention and Wellness Protection

25%

Clinical Evaluation & Diagnosis 22%

Immediate and Emergency Care 19%

Treatment and Rehabilitation 22%

Organizational and Professional Health and Well-Being

12%

Areas of Review

• Legal Requirements• Indications & Side Effects for Drugs:

– Pain, NSAIDs, Asthma, Cold/Cough/Allergy, Performance Enhancing Substances

• Emergency Medications– E.g., Epi-pen, Rescue Inhalers

• Drug Testing & Substance Abuse Issues• Basic Pharmacology

– E.g., Pharmacokinetics, Pharmacodynamics

Course Notes

Course Textbooks

Current LiteratureClinical Experiences

Review Plan

Additional Items Available

• Pharmacology Podcasts– Drug History; Pharmacokinetics;

Pharmacodynamics; NSAIDs; Opiates

BOC References for Pharmacology2011-2012

1. Mangus & Miller. Pharmacology Application in Athletic Training

2. Houghlum & Harrelson. Principles of Pharmacology for Athletic Trainers.

3. Gladson. Pharmacology for Physical Therapists

4. Koester. Therapeutic Medications in Athletic Training.

Scenario #1

• A 22-year old linebacker had a mild concussion during practice 10 days ago. After 1 week without symptoms he was cleared to resume playing.

• He received another mild concussion in the first half of tonight’s game. He was withheld from competition for the remainder of the game.

• At the conclusion of the game his only complaint is a headache. What, if any, medication do you recommend?

Scenario #1

Options

1.No medication– 2nd concussion in last 2 weeks, want to

observe for increased symptoms

2.Tylenol– No ibuprofen slight anti-coagulant so could

increase bleeding if there is a subdural hematoma present

Scenario #2

• A 20-year old female basketball player asks your advice about using different medications.

• She is currently taking Azmacort and Albuterol for her asthma. Since she sprained her ankle 2 weeks ago, her coach has recommended her taking 2-200 mg tablets of ibuprofen each day to reduce the swelling.

• She was also prescribed Serevent for her asthma but hasn’t started using it. Is it safe for her to also begin taking her Serevent with these other medications?

Review Scenario #2

• Drugs currently taking:– Azmacort – Inhaled corticosteroid decreases

inflammation

– Albuterol – Short acting B2-agonist (rescue medication)

– Ibuprofen – not taking enough for anti-inflammatory effect

– Serevent ?? – A long acting B2-agonist bronchodilator

• What should she do?– Discontinue Ibuprofen– Only use Albuterol for “asthma attacks”– Serevent & Azmacort work synergistically

NATA Consensus Statement: Managing Prescriptions and

Non-Prescription Medications in the Athletic Training Facility

Consensus Recommendations

• Create document: Policy & Procedure of Medication Use

• Outlines:– Storage; Documentation; Team Travel– Verification (prescription only); Distribution– Packaging/Labeling; Emergency

Medications– Disposal; Samples

Administration of Medication

• Administration of Medication – 1 dose pack– Each individual receiving the medication

should be informed of the medication and how s/he should take it

• Use Dose Packs– Should not repackage medications FDA 7-

point label guideline

Storage

– “All OTC and prescription medications should be stored in a locked metal cabinet that is environmentally controlled (dry temperature between 59-86 degrees) and secured by tamper-proof locks”

– “Storage should be inaccessible to athletes (and other unauthorized individuals), with access (keys) limited to the facility’s authorized personnel (certified athletic trainers and physician).”

Documentation

• Log Sheet– Patient’s name– Injury/Illness– Medication given– Dose (e.g., 200mg tablet)– Quantity– Lot Number (if possible)– Date Administered

• Transfer patient information to individual chart

Travel

• Domestic Travel– Carry a formulary signed by an advising

physician that identifies each OTC and prescription medication managed by the AT

• Preferred means of communication between the AT and the physician while traveling.

• International Travel– Coordinate with the appropriate government

agencies

Basic Pharmacology

Pharmacokinetics

• Definition: The effect the body has on the drug

• Administration– Enteral – by mouth, sublingual, or rectal– Parenteral – anything else

• Distribution – across membranes

• Metabolism - Liver

• Excretion – usually kidney

Pharmacodynamics

• Definition: The effect of the drug on the body

• Drug Receptor Theory– Lock & Key

• Agonist vs. Antagonist

• Therapeutic Index – Higher is safer

• Steady-state and Half-life

NSAIDs

What is an NSAID?

• Non-steroidal Anti-inflammatory Drug

• Most Common NSAID OTCs– Aspirin (Bayer, Excedrin)– Ibuprofen (Advil, Motrin)– Naproxen Sodium (Aleve)– Ketoprofen (Orudis KT)

• Common Rx:– Celebrex, Voltaren, Relafen, etc

Effects of NSAIDs

• OTC NSAIDS have 4 effects:1. Anti-pyretic (Reduces Fever)2. Analgesia3. Anti-platelet (anti-coagulant)4. Anti-inflammatory

• How does an NSAID decrease inflammation?

Arachidonic Acid (cell membrane)

Arachidonic Acid

PGsProstaglandin

PGI2

Prostacyclin

TXsThromboxane

LTsLeukotrienes

Cox enzyme

Phospholipase A2

Lipoxygenase enzyme

Role of Prostaglandin

• Prostaglandins– Increases vascular permeability (edema);

induces pain– Also protects gastric mucosa by decreasing

acid secretion (PGE2)

• NSAIDs are generally referred to as “anti-prostaglandins”

Arachidonic Acid (cell membrane)

Arachidonic Acid

PGsProstaglandin

PGI2

Prostacyclin

TXsThromboxane

LTsLeukotrienes

Cox enzyme

Phospholipase A2

Lipoxygenase enzyme

Corticosteroids

NSAIDs Singulair, Zyflo

Bronchoconstriction

cause

Arachidonic Acid (cell membrane)

Arachidonic Acid

PGsProstaglandin

PGI2

Prostacyclin

TXsThromboxane

LTsLeukotrienes

Cox enzyme

Phospholipase A2

Lipoxygenase enzyme

Role of Cox Enzyme

• COX-1 produces TXA2, platelet aggregation

• COX-2 produces PGI2, platelet aggregation inhibition (anti-platelet)

• With injury - production of PGI2 is reduced and TXA2 dominates

– Platelets aggregate and lead to blood clot formation

Aspirin & Cox Enzyme

Cox 2 Enzyme = Inhibits Platelet

Aggregation

• Aspirin is primarily a Cox-1 INHIBITOR

– By inhibiting Cox-1 Enzyme = Anti-coagulant

Cox 1 Enzyme = Causes Platelet

Aggregation

Ibuprofen & Cox Enzyme

• Ibuprofen inhibits both Cox-1 & Cox-2, with a slightly greater inhibition of Cox-1 enzyme– Slight anti-coagulant

• Similar Drugs: Aleve (Naproxen sodium)

Cox 2 Enzyme = Inhibits Platelet

Aggregation

Cox 1 Enzyme = Causes Platelet

Aggregation

Celebrex & Cox Enzyme

• Celebrex inhibit only Cox-2 enzyme

– Coagulant

Cox 2 Enzyme = Inhibits Platelet

Aggregation

Cox 1 Enzyme = Causes Platelet

Aggregation

NSAID Dosage for Pain

• Aspirin Dosage

– The antipyretic dose for aspirin and ibuprofen is similar to the dose for relief of mild to moderate pain

– Risk of Reye’s syndrome associated with the use of aspirin in children with fever and after viral infection

NSAIDs and Research

• Some research suggest that NSAID use early after injury will have negative effect on healing of tissues (Johnson & Stovitz, Physician & Sports Medicine, 2003).

• Some “Tendonitis” injuries had no inflammatory component

Course Notes

Course Textbooks

Current LiteratureClinical Experiences

Review Plan

Additional Items Available

• Pharmacology Podcasts– Drug History; Pharmacokinetics;

Pharmacodynamics; NSAIDs; Opiates

Questions