About the authors
Cole Papakyrikos, MD, is a pediatric resident at Johns Hopkins Children’s Center in Baltimore, Maryland.
Teri Metcalf McCambridge, MD, specializes in pediatric sports medicine at Towson Orthopaedic Associates in Towson, Maryland.
Healing the young athlete with OTC medications
Publication
Article
Contemporary PEDS JournalAugust 2022
A variety of nonprescription treatments, supplements, and patches can alleviate pain for children and adolescents.
Musculoskeletal injuries, especially those due to repetitive use, are common in child and adolescent athletes.1 The most recent Centers for Disease Control and Prevention data showed that there were more than 2.7 million annual emergency department visits for pediatric sports injuries from 2010 to 2016. These data suggest that many pediatricians have likely treated or seen a child acutely or in follow-up for a sports-related injury.2 Pediatric health care providers are most likely familiar with the mnemonic PRICE: protection, rest, ice, compression, and elevation. This does not mention medications. The most common medications used for sports-related injuries include nonsteroidal antiinflammatory drugs (NSAIDs), acetaminophen, and lidocaine patches. Fortunately, most of these medications are available OTC.
The 2 most widely used oral NSAIDs for musculoskeletal injury are ibuprofen and naproxen, with naproxen often recommended by sports medicine clinicians due to its longer half-life. They provide analgesic, anti-inflammatory, antipyretic, and antithrombotic effects by inhibiting cyclooxygenases and subsequent cessation of the creation of prostaglandins from arachidonic acid.3 Jin et al performed a meta-analysis examining acute analgesic usage in emergency departments for pediatric musculoskeletal injuries.4 They found that oral ibuprofen produced better analgesic effect 60 minutes after administration and equivalent effect at 30 minutes when compared with acetaminophen, acetaminophen with codeine, and morphine. Results of this study,4 as well as those of a seminal study published in 2007 in the journal Pediatrics,5 showed ibuprofen to be superior to acetaminophen for the treatment of acute musculoskeletal injuries.
Although NSAIDs provide excellent analgesia acutely, there have been some concerns about prolonged usage for treatment of musculoskeletal injuries. Some studies have looked at whether the antiinflammatory and antithrombotic properties of NSAIDS can be detrimental to the healing process and increase bleeding risk, but these concerns are founded in animal models and have not been proven in human clinical trials.6,7 A review of prospective and retrospective studies examining NSAIDs effects on bone healing in children did not reveal any increased risk for pseudoarthrosis or nonunion after medication use.8 Similarly, in muscle strains there is no clear evidence to suggest that NSAID use delays or impairs muscle repair.9 Due to this incomplete evidence base, NSAIDs are generally used in the first week of injury and discontinued thereafter.
In addition to the debate over the effects of NSAIDs on healing, there are also many well-known risks associated with prolonged use of the medication. Prolonged and even short courses can cause damage to the gastrointestinal mucosa and reversible reductions to glomerular filtration.10 Whereas the renal effects are reversible, there is research to suggest that prolonged usage of ibuprofen during activity may lead to acute kidney injury.11
In addition to oral NSAIDs, topical NSAIDs in the form of diclofenac are available OTC. The local administration of this medication reduces the systemic adverse effects (AEs) while treating inflammation and pain secondary to sprains, strains, and contusions.12 There are limited data available for its efficacy in treating pediatric sports injuries. However, a Cochrane review examining studies in adults showed that topical diclofenac produced clinically significant pain relief in acute sprains and strains.13
Acetaminophen is another common analgesic used to treat musculoskeletal injuries in children. Although its exact mechanism is not known, it provides both analgesic and antipyretic effects, and as previously mentioned is generally considered slightly inferior to relieving musculoskeletal pain when compared with NSAIDs. Despite this, acetaminophen has far fewer AEs when compared with prolonged NSAID use and can be used to treat lingering pain after initial NSAID courses have been discontinued.14 It is, therefore, more commonly used in injuries that produce chronic pain.
Lidocaine 4% patches are additionally available OTC and are approved by the US Food and Drug Administration for treatment of athletes 12 years and older. The medication works as a local analgesic agent by blocking the initiation and conduction of nerve impulses through sodium channel blockade. The patches may be applied to athlete’s intact skin overlying areas of pain. Unfortunately, there is little pediatric evidence to demonstrate the patches’ efficacy, and the evidence in the adult literature is limited and of low quality.15 For some adolescent athletes, this medication can assist in pain control and is a safe adjunct to recommend. These patches should be avoided in patients with open wounds, skin eczema, and hypersensitivity to amide anesthetics.15
Capsaicin, menthol, and camphor are common ingredients in OTC ointments used by athletes in treatment of musculoskeletal pain. Both function as counterirritants that excite then desensitize nociceptive sensory neurons.16 Capsaicin is available OTC in creams, gels, ointments, and patches in low concentrations that have been shown, in limited studies, to provide pain relief for musculoskeletal injuries over time.16 However, it is primarily used for neuropathic pain and when misused can result in irritation and chemical burn. Similarly, menthol has been shown to decrease pain due to muscle soreness or stain in limited studies but is readily available in many OTC preparations.17 Clinicians should use caution with preparations that contain methyl salicylate as overuse or application to inappropriate areas may lead to salicylate toxicity.18
A final OTC medication used as supplemental analgesia in the treatment of pediatric musculoskeletal injuries is arnica. Arnica is an OTC herbal supplement derived from the Asteraceae plant family and is available as a topical gel or cream.19 The Asteraceae plant family contains daisies, marigolds, and chamomile. Arnica has been found to have multiple pharmacologic properties including anti-inflammatory, analgesic, antimicrobial, antirheumatic, and antiarthritic effects. There is some evidence in the adult literature that use of arnica cream can provide effective analgesic properties in management of ankle sprains, it however has not been substantially studied in pediatric patients.20 Its possible AEs range from dry mouth, headache, and drowsiness to gastroenteritis, emesis, diarrhea, tachycardia, bleeding, and cardiac arrest. It is therefore recommended that patients limit arnica use to topical gels that have AEs limited to local dermatologic and allergic reactions.20
Overall, NSAIDs are the predominant OTC medication choice for a wide array of pediatric musculoskeletal injuries. Clinicians should remain wary of their prolonged use as there is insufficient evidence to determine the effects of their antiinflammatory properties on overall muscle healing. Adjuncts such as lidocaine patches and arnica cream can be helpful aids in treatment of pain when NSAIDs or acetaminophen is not enough.
References:
References
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8. Choo S, Nuelle JAV. NSAID use and effects on pediatric bone healing: a review of current literature. Children (Basel). 2021;8(9):821. doi:10.3390/children8090821
9. Heer S, Callander JW, Kraeutler MJ, Mei-Dan O, Mulcahey MK. Hamstring injuries: risk factors, treatment, and rehabilitation. J Bone Joint Surg Am. 2019;101(9):843-853. doi:10.2106/JBJS.18.00261
10. de Martino M, Chiarugi A, Boner A, Montini G, De’ Angelis GL. Working towards an appropriate use of ibuprofen in children: an evidence-based appraisal. Drugs. 2017;77(12):1295-1311. doi:10.1007/s40265-017-0751-z
11. Lipman GS, Shea K, Christensen M, et al. Ibuprofen versus placebo effect on acute kidney injury in ultramarathons: a randomised controlled trial. Emerg Med J. 2017;34(10):637-642. doi:10.1136/emermed-2016-206353
12. Jones CA, Hoehler FK, Frangione V, Ledesma G, Wisman PP, Jones C. Safety and efficacy of the FLECTOR (diclofenac epolamine) topical system in children with minor soft tissue injuries: a phase IV non-randomized clinical trial. Clin Drug Investig. 2022;42(1):43-51. doi:10.1007/s40261-021-01101-x
13. Derry S, Wiffen PJ, Kalso EA, et al. Topical analgesics for acute and chronic pain in adults - an overview of Cochrane Reviews. Cochrane Database Syst Rev. 2017;5(5):CD008609. doi:10.1002/14651858.CD008609.pub2
14. Caes L, Fisher E, Clinch J, Eccleston C. Current evidence-based interdisciplinary treatment options for pediatric musculoskeletal pain. Curr Treat Options Rheumatol. 2018;4(3):223-234. doi:10.1007/s40674-018-0101-7
15. Derry S, Wiffen PJ, Kalso EA, et al. Topical analgesics for acute and chronic pain in adults - an overview of Cochrane Reviews. Cochrane Pain, Palliative and Supportive Care Group, ed. Cochrane Database Syst Rev. 2017;2020(2). doi:10.1002/14651858.CD008609.pub2
16.Loveless MS, Fry AL. Pharmacologic Therapies in Musculoskeletal Conditions. Med Clin North Am. 2016;100(4):869-890. doi:10.1016/j.mcna.2016.03.015
17.Pergolizzi JV, Taylor R, LeQuang JA, Raffa RB, the NEMA Research Group. The role and mechanism of action of menthol in topical analgesic products. J Clin Pharm Ther. 2018;43(3):313-319. doi:10.1111/jcpt.12679
18. Thompson T, Toerne T, Erickson T. Salicylate Toxicity from Genital Exposure to a Methylsalicylate-Containing Rubefacient. West J Emerg Med. 2016;17(2):181-183. doi:10.5811/westjem.2016.1.29262
19. Kriplani P, Guarve K, Baghael US. Arnica montana L . – a plant of healing: review. J Pharm Pharmacol. 2017;69(8):925-945. doi:10.1111/jphp.12724
20. Smith AG, Miles VN, Holmes DT, Chen X, Lei W. Clinical trials, potential mechanisms, and adverse effects of arnica as an adjunct medication for pain management. Medicines (Basel). 2021;8(10):58. doi:10.3390/medicines8100058
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