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NSAIDs and Dehydration risks to the Kidneys
#218936 10/06/11 09:53 PM
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Just wanted to pass for discussion something I learned recently. I'm fortunate that I'm able to manage AS to a zero currently with the use of Meloxicam. I'm able to run 60-80 miles per week and race competitively (weekend warrior type) typically without any AS related issues. I'm becoming more and more convinced the AS and the running are completely independent variables for me - i.e. running doesn't seem to make me more prone to AS inflamation - and in fact might even be reducing it somewhat. But I certainly see a corrilation between the NSAIDs and the Inflamation. I've been kinda searching for a minimum dosage level and went to 7.5mg/day for a while but the inflamation set in a few weeks ago - I upped to 15 mg/day and all pain was gone again with a few days. While the pain was there I was completely unable to run - I could maybe go 1/2 mile - I could bike - and actually a long bike ride (3 hours)after about 2-3 days at 15 mg/d and I was pain free again right after the bikeride - almost seemed like the bikeride helped to get rid of it.

FWIW - my rhuemy hasn't guided me to reduce running as long as I have no hip or knee symptoms which I never do - for me the inflamation is always in my right SI joint area - very little indication shows up on X-Rays in the SI joint only - no where else.

A couple weekends ago I ran an UltraMarathon - 50 mile race (first attempt at anything beyond a marathon). At one point I got completely dehydrated in the race and had to stop and drink a bunch and take in electrolytes then proceded on slower with lots of drinking and elecrolytes. As I looked around for why I got so dehydrated I was wondering if the NSAIDs could be related to dehydration - from what I've read it appears probably not but I happenned to come across some rather scary stuff about how when your dehydrated - the kidneys will naturally alter blood flow to protect themselves however NSAIDs screw that up. So while on NSAIDs it seems it is a really bad idea to let yourself get to a dehydrated state - can do long term kidney damage and maybe can even cause death.

Anyway - I thought I'd pass that along and see if there is other medical or individual experience around that reinforces this or not. The warnings articles I've seen seem to be targeted more at the occasional NSAID user than the regular NSAID user and it could be the risks are not so much for the regular but I don't know - not something I want to mess around with so I'll be taking extra precautions to not allow myself to get dehydrated in the future. Actually it's also making me think a little more about going the Enbrel route - but I probably won't for now since what I'm doing now seems to be working OK.

Thoughts?

John.

Re: NSAIDs and Dehydration risks to the Kidneys
Hill #218946 10/07/11 12:35 AM
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I don't know the answer but it's a good question, John. A few years ago I was a regular runner (not nearly at your level!!) - 15-30 mpw more like it. I gradually slacked off for a variety of reasons, not related to my pain though.

Anyway - at that time I used to post a lot at the online forums at runnersworld.com. I remember many conversations about "vitamin I." In the Nutrition forum there are a number of knowledgable folks who may be able to provide some answers or point you in the direction of some answers.

I would bet there is little or no scientific evidence on this topic in re: folks who are on high dose therapeutic NSAIDs as we are, but it doesn't hurt to look/ask.

Maybe you just had an off day during that ultra? That's certainly a hella long distance!! My hat is off to you for even attempting it, AS or no AS wink


Jen, 42, happy partner of James and Moma to Evan, 14, & Lucy, 12.5 (Crohn's dx @ age 3; on Remicade since April 2010.) I take piroxicam, Flexeril, & Nucynta ER nightly. 3 anti-TNFs didn't pan out for me.

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Re: NSAIDs and Dehydration risks to the Kidneys
JenInCincy #218964 10/07/11 03:33 AM
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What you've read about NSAIDs does have scientific basis, to my knowledge - NSAIDs block prostaglandins (part of their anti-inflammatory effect). Certain prostaglandins are made in your kidneys, and inhibiting them can result in a decrease in blood flow to your kidneys (and thus a decrease in how effectively they can filter/balance electrolytes and water in your body) - if you're dehydrated on top of that, the decrease in blood volume (from dehydration) will further compromise kidney perfusion and thus filtration. However, in a healthy person (i.e. no congestive heart failure, cirrhosis, or diuretic meds), it's rare that NSAID use alone would result in acute kidney failure, unless you're otherwise seriously stressing them out.
Hope some of that was helpful...


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Re: NSAIDs and Dehydration risks to the Kidneys
medpgh #219032 10/08/11 09:51 PM
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@Jen - Thanks for the RW pointer - I've posted lots over there but I've never ventured to the Nutrition forum. Another forum (letsrun) I got what seemed to be some knowledgable input. Yeah I've got a lot to learn before I tackle another Ultra - I didn't really do enough practicing to figure out the right hydration/fueling strategy so no big surprise the results - but it was a fun experience anyway.

@medpgh - thanks for the input - I'm beginning to think the risks aren't that great - with an ounce of prevention to prevent - as you say - seriously stressing them out - I suspect I should be fine. I just need to figure out how to not get dehydrated in these ultra-type events.

Re: NSAIDs and Dehydration risks to the Kidneys
Hill #219154 10/11/11 07:14 PM
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Interesting, I've posted many times about not being able to run well or recover from exercise anymore. I'll have to keep track of if I have these bad running days when I take a NSAID. I feel as if something is preventing me from having enough energy, whether that be an actual metabolic or lung issue or just AS restricting my lungs or my kidneys not allowing my body to have enough electrolytes I have yet to figure out. However every time I see a homeopathic doctor they say "sounds like you need more electrolytes when you run." Please keep me posted if you find any other information on this topic. thanks

Re: NSAIDs and Dehydration risks to the Kidneys
Hill #219156 10/11/11 07:20 PM
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Interesting, I've posted many times about not being able to run well or recover from exercise anymore. I'll have to keep track of if I have these bad running days when I take a NSAID. I feel as if something is preventing me from having enough energy, whether that be an actual metabolic or lung issue or just AS restricting my lungs or my kidneys not allowing my body to have enough electrolytes I have yet to figure out. However every time I see a homeopathic doctor they say "sounds like you need more electrolytes when you run." Please keep me posted if you find any other information on this topic. thanks

Re: NSAIDs and Dehydration risks to the Kidneys
#221540 11/16/11 05:07 PM
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rivercanoeist - thanks for the feedback. I've got a couple ultra events planned for next year so this is something I need to do some experimenting to be sure I'm taking the proper precautions. I do find it interesting you can detect the problem with creatanine levels - I'll be sure to get that checked before I start the training so I can baseline and be sure I'm being successful in not impacting the kidney - is this a standard thing checked for? If so I may have past data to be sure I haven't done anything already.

Yeah I know drinking more is certainly the solution - I suspect in my case I will need to slow down too as it just may be my sweatrate at higher speeds is too fast to be possible to drink enough - I suspect I'm water limitted before I'm aerobically limitted which means I need to be extra careful to find the right pace to not over do it - like I said - I'm going to have to do some experimenting with how fast I loose and how much I can drink at different paces to be sure I stay in a "safe" zone.

Re: NSAIDs and Dehydration risks to the Kidneys
#222015 11/23/11 03:12 PM
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Thanks again for the response - I'm not yet convinced I can go full out. For racing up to the marathon I think I'm OK as long as its not especially hot/humid for the race. But my events for next year are an Ironman (~10 hours) and maybe a 100 miler depending on a lottery draw next month (~24 hours). Full out in these sports for me is pretty negative hydration over the time as I'm a pretty heavy sweater so I'll need to be maxing the drinking (~24 oz/hr is about all the stomach can pass) and find what intensity I don't loose much weight over time - I suspect that is going to be much less than full out at least for the 24 hr race - for the 10 hr I can probably get much closer to full out because the intensity on the bike is naturally lower than the run.

Yeah it is kinda scary the Doctors' don't warn of this stuff. I've considered switching to a TNF blocker just to not have this worry but the NSAIDs are doing so well I figure its better to manage the risks.

Re: NSAIDs and Dehydration risks to the Kidneys
Hill #222068 11/24/11 04:10 PM
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Just my .02. After many good years on Voltaren my Alaskan Rheum took me off it. He was very clear about it. I switched to Aleve and after the last year it has worked for me. I take 2 Aleve and 1 long acting Tylenol with food and it holds me for about 10 hours. I asked my new Rheum here in San Diego and he emphasized the studies still reveal that Voltaren is rough on the heart. He also wants me to take Omeprazole daily but I don't take enough Aleve to justify adding another medication in my mind.


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Re: NSAIDs and Biologics
#222293 11/29/11 04:31 PM
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rivercanoeist - thanks for sharing your experience on this!

- to your questions:

1) do you feel normal when you take them?

yes - I don't feel so different with or without them except if I go without them for a while I feel low level pain/inflamation around the SI joint area. I will try to cut them down although I'm actually finding the trend is to be taking more. First few bottles I could make a month's supply (15mg/d) last for 6-7 weeks where the latest was closer to 5 weeks. (I'm about 8-9 months since DX)

2) if you find that you can skip a couple of days of taking one stay on them

I've forgotten for a couple days and restarted without much consequence but if I cut to 1/2 dose for more than a week I start to feel stuff - at least that was true last time I did it - not so sure this thing is really so predictable all the time - once I let it get to the point of feeling something it seems like it will keep progressing and knock me off the running for a few days and add a little limping to my walking from SI joint area pains before I can get the upped dosages to take away the inflamation again so I've been a little leary chopping down very quickly.

So I guess with those responses you'd suggest I stick with the NSAIDs. I'm not so afraid of biologics but they have their drawbacks for an endurance athlete too for example my immunity system takes a pretty big hit with each big event or even big workout and I have to take special care to not get sick - sometime I take airborne for example to be premptive. I would be double prone with the biologics. I'm kinda wondering if I can do a switch back and forth kinda thing using one or the other depending somewhat on what I'm doing - I was going to talk to my Rhuemy about the pros/cons of this idea.

I'll take a look into the proton pump inhibitor option. I've wondered about Ulsers and if they are permanent or not - could it be after I get one after perhaps a few years of NSAIDs I could switch to the biologicals and it would heal back up again or is it more like once you get em your stuck with them forever.

fwiw - I did find what appears to be a pretty good study showing what changes with NSAIDs at anti-inflamitory dosages during Exersize (rofecoxib - a COX-2 inhibitor - I presume a reasonable approximation to Meloxicam which I take).

Link

Main take away's I got:
- Never volenteer for a test like this (I just don't even want to go there with rectal temps while running/cycling).
- NSAIDs reduce how much body temperature increases from exersize similar to how taking them for a fever will reduce the fever.
- sweatrate is no different w or w/o NSAIDS - this gives me some reassurance that NSAIDs don't actually cause dehydration - rather it seems more the issues are the risk-factors while dehydrated - so the message is don't get dehydrated.
- heartrate was on average 6 bpm lower with NSAIDs - as I uses heartrate in my training this was interesting for me and actually matches up pretty well with how my training heartrate zones have changed with the NSAIDs (maxHR at the end of a 5k race with NSAIDs was 176 where last year without NSAIDs at a similar fitness and race weather it was 182).

Cheers.

Last edited by Hill; 11/29/11 04:38 PM.
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