Stuart, Mark Campbell; (2024) The essential and optimal analgesic and anti-inflammatory medicines for athletes at the Olympic Games. Doctoral thesis (Ph.D), UCL (University College London).

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Abstract

Background. At every Olympic Games, a comprehensive set of medications is selected to be provided through the polyclinic pharmacy and wider medical services primarily for the treatment of athletes. This is known as the games formulary, and usually consists of 200-300 different types of drugs chosen to meet the expected medical needs encountered in this unique sport setting. This formulary constitutes the list of medicines that are available for prescribing for athletes at the event by both local physicians and visiting international team physicians. At the Olympic Games this formulary has always been constructed on a games-by-games and country-by-country basis, and thus has usually reflected the national formulary and availability of medicines used by the host country. This process has inevitably led to significant variations and inconsistent standards in medicines provision between games in terms of efficacy, quality, safety, and costs of service delivery, even though the athlete population being served has remained relatively consistent in terms of their pharmacological needs. In 2019, the International Olympic Committee (IOC) published the first Olympic and Paralympic Model Formulary (OPF),1 which for the first time presented a standardised set of medications required to be available at every Olympic and Paralympic Games starting from the Tokyo 2020 Olympic Games, but was also implemented prior to this at the Minsk 2019 European Games. The OPF provides all healthcare providers from both the host country and visiting teams with a consistent, safe, and clinically relevant selection of medicines to prescribe to athletes during the games. The OPF must be representative of the medications athletes are taking and what physicians are prescribing to them during the games, while at the same time reflecting a set of consistent and dependable treatment options which are both safe and effective. /   Aims. The overall aims of this study were to: i) Determine whether the OPF meets both the clinical needs of the athlete population, and the prescribing expectations of team physicians relating to the treatment of musculoskeletal sports injury with medicines for pain and/or inflammation (PI) during international games; ii) Present a revised and optimised set of essential PI medications for the Olympic Games, which will inform future editions of the OPF, and; iii) Establish a quantitative, reproducible approach to the selection of medicines for the OPF which can be implemented for future games to enable continual updating of the OPF over time to reflect the changing medication needs of athletes. / Methods. This research was carried out in two phases (Phase One, proof-of-concept pilot study: European Games, Minsk 2019, and Phase Two: Olympic Games, Tokyo 2020 Summer Olympic Games and Beijing 2022 Olympic Winter Games). Phase One involved a qualitative review of data collected from four sources including: i) doping control forms (n=999), ii) pharmacy dispensing reports from the athlete village pharmacy (n=471), iii) medication importation declarations by National Olympic Committee (NOC) teams (n=36), and iv) survey of team physicians (n=60). Phase Two involved a quantitative analysis to determine a revised recommended list of PI medications for the OPF. It included the collection of actual medication-use data of Olympic athletes (n=6155) from 3 separate sources to establish the prevalence, including: i) doping control forms, ii) pharmacy dispensing reports from the athlete village pharmacy, and iii) injection declaration forms required submitted according to the IOC Needle Policy. Validation of the results included two further data sources: iv) medication importation declarations by NOC teams (n=156), and v) survey of team physicians (n=382). / Results. Phase One at the European Games showed that 23.1% (n=231) of athletes selected for testing declared the use of one or more PI medications in the previous 7 days on the doping control forms. Of all PI medications declared by athletes, 80.0% (n=252) were listed on the OPF, with NSAIDs accounting for the majority of all PI medications declared (70.8%, n=223). Of all PI medications imported as team stock, 36% were listed on the OPF, but 44% could be covered by a suitable alternative medication in the same therapeutic class for the same indication. Of all physicians completing the team physician survey, 68.3% (n=41) indicated 75-100% of PI medications they prescribed were covered by the OPF. This pilot study identified use of a number of PI medications taken by athletes documented to have significant safety concerns, including metamizole, piroxicam and nimesulide. Phase Two showed the overall prevalence of PI medication use by Olympic athletes was 36.7%. NSAIDs were the most used class of PI medication, with 27% of athletes reporting use. Female athletes had a higher prevalence of PI medication use compared to male athletes (f: 44.1%; m: 30.0%; p<0.001). The prevalence of PI medication use was higher in older athletes aged 30-34 (42.0%), and in athletes from the Pacific region, where over half (52.2%) of athletes reported using PI medications. Sports with the highest prevalence of PI medication use included: weightlifting (65.6%), gymnastics (58.1%), handball (55.0%) and volleyball/beach volleyball (54.5%). With the exception of corticosteroids for intra-articular use, there was no significant difference between the prevalence of PI medication use between the Tokyo and Beijing Olympic Games. Further use of PI medications by athletes with safety concerns were identified, including rofecoxib, nimesulide and metamizole. By systematically applying a prevalence-based threshold for inclusion, a revised list of 48 PI medications was recommended (9 new, 13 deleted). This was validated through review of the imported team medications, with the most frequently stocked medications in 94% (n=17) of PI categories represented. Furthermore, the team physician survey demonstrated that the revised list covers the most frequently prescribed medication in each PI category. If the revised list of PI medications was implemented in the same athlete study population (n=6155) across the Tokyo 2020 and Beijing 2022 Olympic Games, it would lead to a 7% improvement in terms of numbers of athletes who could have their exact PI medication requirements met by the OPF (n=244). / Discussion and Conclusion. The research led to the determination of the prevalence of PI medication use by athletes at the Olympic Games. It also led to a revised and optimal set of PI medications to be listed in the official OPF that can better serve the actual medical needs of athletes, which is aligned to the prescribing expectations of team physicians. It led to a key finding of the current use of drugs with harmful risks to athlete health. Through this study, a systematic, reproducible, and quantitative approach was developed which can be used to continually determine the optimal and essential set of medicines to be available for the treatment of pain and inflammation for athletes at all future Olympic Games.

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