Friday, April 20, 2018

Medications and Running

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As a runner, I hear all the time about how someone should take this or use this to help treat various problems.  Although most times these are usually decent recommendations, the pharmacist in me can't help but interject whenever I hear this.  Rather than criticize all of the bad advice I've heard, I decided to make a relatively complete list of common medications, what they are used for, and how their use relates to running.  I tried to include some brand and generic names to minimize confusion for everyone as well.

Please let me know your thoughts and questions, I'd be glad to help!



NSAIDs (ibuprofen, Advil, Motrin, naproxen, Aleve, meloxicam, etc.) - These are all general pain relievers for running related injuries and to help bring down inflammation.  Definitely should be taken with food to avoid upsetting the stomach, or at least a gel and lots of water if need while running.  Possible issues with high doses and ultramarathon running due to the kidney affects.
Remember, that if you have serious pain it is a sign your body is possibly 
experiencing something that isn't right.
At the very least, stop and do a systems check of yourself.
It's OK to push yourself but don't break yourself

Aspirin - Not much a role here as a pain reliever.  Can be used prior to long flights or drives to races to help minimize the chance of forming blood clots.  Some studies have linked its anticlotting effects to helping reduce cramps in long distance running.  Take with food and watch for stomach pain with this in high doses or chronic use.

Acetaminophen (Tylenol) -  Good overall pain reliever but doesn't help to reduce inflammation, so not the best thing for most running injuries.  Doesn't have to be taken with food and can be used with NSAIDS to help reduce pain.

Pseudoephedrine (Sudafed) - Great decongestant but can really elevate heart rate and blood pressure.  Don't use while running as this can really can cardiac stress.

Ephedrine (Bronkaid) - Good over the counter medication to help relieve some asthma and breathing issues, but avoid in running.  This medication is sometimes used as a performance enhancer (like it's cousin pseudoephedrine) and has been linked to the possible death in several athletes, due to the affects it has on heart rate and blood pressure.  
Commonly used in weight loss plans known as ACE stacking, do NOT use this method!

Phenylephrine (Sudafed) - Weaker decongestant than pseudoephedrine, but still has the same risks.

Cough medicines - ALWAYS read your labels! Many cough medicines have multiple ingredients and several in any one product may not be right for your symptoms and hurt your running.

         Guaifenesin (Mucinex) - Good for helping to break up mucus in the lungs and coughing up.  Mixed reviews on it's effectiveness but safe to use while running or helping fight a cold while getting your miles in.
When sick, run conservatively! 
Your body is under a lot of stress fighting sickness off, don't push it over the hill by running.
Take it easy and dial it back a bit.

         Dextremethorphan (Delsym, DM) - Good for stopping a cough so you can get some sleep at night and recover.  Can be used while running, but limit use.  Coughing helps clean out the lungs, stopping it can leave irritants in the lungs.  Can make some people dizzy or "trippy".

Antihistamines - Generally split into two classes due to their strength and likelihood to make a user drowsy.  commonly found in many cough and cold combination products

         Non-Drowsy (loratadine, Claritin, cetirizine, Zyrtec, fexofenadine, Allegra) - Great for seasonal allergies, paricularly if the allergies are too bad or the allergan count isn't too high.  Cetirizine can cause some drowsiness, the others generally won't and are better to take if running because of this.

         Drowsy (diphenhydramine, Benadryl, chlorpheniramine, Chlor-Trimeton) - Great for all allergic reactions or allergies but can really leave the user drowsy.  Some of these can also be used as sleep medications, so avoid use prior to races.

Nasal Sprays - Various types with various uses, watch this as they are usually sold near each other and marketed similarly

         Nasal Steroids (fluticasone, Flonase, mometasone, Nasonex, etc.) - Great for seasonal allergies as they stop the immune response and don't cause the drowsiness of antihistamines. Some forms of fluticasone have alcohol and may cause nosebleeds, mometasone usually does not.

         Decongestants (oxymetalzine, Afrin) - great decongestant with limited risk of cardiac issues, especially compared to pseudoephedrine or phenylephrine. Should only be used for 3 days or less as they can caused rebound congestion if used longer.  

         Saline (Ayr, Deep Sea) - Good for cleaning out the nose and helping to relieve most nasal symptoms, can be used quite often too.

Loperamide - Good for treating diarrhea. Safe to use while running but be careful to not cause problems by taking this unnecessarily
Runner's trots are a thing and are normal. Avoid taking loperamide preventatively.
Most races have port-a-potties.

Constipation medication - Most runners do not suffer from this issue. This is just here for completeness sake and to not how they work.

         Polyethylene glycol (Miralax) - works by drawing water into the colon and helping to form stool. Not ideal for runners as dehydration is already a risk of the sport, this might make it worse

         Bisacodyl (Dulcolax) - increases the movement of the GI tract to help make stool.  Most runners can get some cramps as physical activity helps work the same way, again not ideal.

         Docusate (Colace) - Stool softener that works to help make it easier to pass a stool.  Probably the best choice for runners but can lead to very soft stools.

         Senna (Senokot) - works similar to bisacodyl, with similar results.  In many "natural" constipation remedies.

Caffeine - In many products that runners use including some beverages, gels, chews, etc. Can increase heart rate and blood pressure and has a diuretic effect.  Limit use to small and infrequent doses, ensure enough water is consumed as well to help prevent dehydration.  Not a lot of benefit for the risks. Some runners swear by it, but be very careful. More benefit in ultrarunning as fatigue and sleeplessness is a bigger issue.
Caffeine has a takes a surprisingly long time to get out of the body.  Generally avoiding it a day or two before races is a good idea to ensure your hydration is ideal for race day.

B-Vitamins - Good to take in certain types of anemia or in a daily multivitamin.  Will not "give energy" as most supplements claim. Little to no negative effects though.

Vitamin D - Most reports now show people who live in the northern part of USA need more of this.  Most outdoor runners get more than less active people, but still OK to take in moderate doses.  It's a good idea to get a blood level drawn from a provider before taking regularly or in high doses.

Calcium - New evidence shows it is best to get calcium through diet and supplements may lead to cardiac issues. Some specialists have recommended these to help with things like shin splints or to recover from broken bone issues.  Generally should be avoided unless a professional recommends them.

Garcinia Cambogia - Going tangential here for a moment, most things marketed for weight loss do NOT work.  Most things marketed by Dr. Oz as miracle products or anything like that do NOT work.  The man is a quack at best.

Creatine - Thought to help the body store water in the muscles. Limited if any actual benefit is proven from using this in lifting or in endurance sport. Probably a waste of money all around

Steroids (prednisone, methylpredinsolone, Medrol) - Great for most running injuries that have swelling or if there are breathing issues with an infection. Would avoid running while on these as the body needs to recover properly but some light running could be OK, check with prescriber. Can give someone the feeling of energy but should be taken with food to avoid stomach issues.

Antiobiotics - There are many classes here but just some of the more commonly prescribed ones are included for brevity. Of note, if sick running should be limited so the body can focus on recovering from that and not the run. With all of these, stay hydrated, keep it light and most can cause diarrhea so watch for that.  Not everyone is Michael Jordan and performs best with a killer instinct when sick, even he said he regretted how he felt after some of his epic games when sick.
Do not tell your provider what antibiotic to prescribe!
They will make the best judgement based on IF you need antibiotics (many cases do not warrant them) and what is the best choice to kill the bacteria bothering you, should you need them.  You can help direct their decisions but remember running is fun but your overall health is more important.

         Penicillin related (amoxicillin, penicillin, cephalexin, etc.) - Generally safe for runners to take and continue to run.  Little to no issues with anything running related unless running ultramarathons while taking, which is ill advised for multiple reasons.

         Doxycycline - Generally safe for runners but may make skin more sensitive to sun, use sunscreen as recommended for outside use anyways. Avoid taking with multivitamins and calcium containing foods.

         Flouroquinolones (ciprofloxacin, Cipro, levofloxacin, Leavquin, etc.) - Avoid in runners and most athletes.  While these due have a time and place to use them, be very careful as this class of medications is known to cause tendon issues, especially in athletes. If these are needed, take it very light, stay hydrated and don't over stretch.

         Macrolides (azithromycin, Zithromax, erythromycin, Ery-tabs, etc.) - Watch for any sort of cardiac issues or chest pain with this class that is known to prolong the QT invterval, which means it can affect your hearts electrical activity.  

         Clindamycin - Safe to use while running, diarrhea is very common as well as stomach issues.  Probably not the best choice due to side effects but little other risks.

         Nitrofurantoin (Macrobid) - Super important to stay hydrated with this antibiotic as it is excreted mainly  through the kidneys and needs a minimum level of kidney function to work. Few other issues.

         Metronidazole (Flagyl) - Generally safe for runners, but alcohol must be avoided while taking this.

Oseltamvir (Tamiflu) - Should avoid running while taking this medication, not because of this medication but because the flu is seriously dangerous.  Take long walks or light hikes instead.

Opiates (hydrocodone, Vicodin, oxycodone, Percocet tramadol) - If someone is on opiates, they probably shouldn't be running.  The cause of pain would determine if they should run or not. Opiates are highly addicting, which can be dangerous as many long distance runners have addictive personalities. Opiates also cause a great deal of constipation, which physical activity can help with, but should be cautioned. Judgement can also be very clouded while taking these and these will make users tired. Injuries might get worse while running on these, especially since the feeling of pain is blocked or limited.

Muscle relaxers (cyclobenzaprine, methocarbamol, tizanidine, baclofen) - Much like opiates, someone probably shouldn't be running these.  Injuries could get worse while running with these and all muscles may not fire quite as they should. Judgement can be impairment and can make the user tired.

Antidepressants - This term is being used a little loosely here to cover a few of that many psychiatric medications out there.  Most of these are totally safe to use while running, almost all of them do have warnings that if your depression (or other psychiatric conditions) worsen make sure to let a medical professional know.  If suicidal thoughts occur or become common, PLEASE call 1-800-273-8255, they can help.  Read the patient information with these, mainly to understand these medications but do not stress about all of this information. Share any possible side effects with a medical professional to seek their advice.


I'm taking an aside here to call out something I've recently seen on the social media and even in running groups.  The picture below is NOT based on fact.  Yes, nature bathing is a thing that can help improve your mood.  Yes, getting outside and being active can make you feel better.  Some people need more than this and we should NOT shame them for needing medications.  Depressions, bipolar, anxiety, schizophrenia and other mental health conditions are real and yes many runners can suffer from them.  We should embrace them trying to help themselves, not shame them for it.
This is FAKE news:

This is the TRUTH:


        SSRIs (citalopram, Celexa, fluoxetine, Prozac, etc) - Generally safe to use while running and are usually the first thing tried to treat depression or anxiety.  Mayt take several weeks to fully work and not cause a tired feeling. Not a lot to really watch for, other than be sure to take regularly and avoid abruptly starting or stopping with out medical advice advising such.  

        Buproprion (Wellbutrin, Zyban for smoking cessation) - Generally safe to use, but some reports have found that this may actually make runners slightly better at endurance sports. Those same studies also showed while athletes could go longer, they were also more susceptible to push themselves to the point of collapse and had some intolerance to heat.  Knowing your limits in running is key while on this medications.

Birth Control - Almost all are safe to run with.  Some of these do have mild potassium sparing diuretics, which are considered performance enhancing drugs despite not really doing much. Let the proper authorities know if you are on birth control and this is a concern.

Seizure medications - If someone has seizures, they should definitely look into if running is safe for them.  If anything start small and run with a friend who has a cell phone, just in case.  While running may help reduce stress for some and thus prevent seizures, for others the physical stress may actually induce seizures. There has been documentation of runners with seizures running marathons and taking medications like diazepam on the course to help stave them off.  Although this does sound like an amazing and inspiring battle of illness, it is probably not the safest course of action.
Rather than dive into this class, I'd advise anyone with seizures to be careful.

Blood pressure medications - This may be the hardest class of medications to take and continue running. Any person who has high blood pressure knows that physical activity is good for reducing blood pressure long term, however it can spike blood pressure in the short term.  There is a balancing act with these medications and running. There are many types of blood pressure medications, this is a quick overview of the most common ones used in first or second line treatment. Cardiac issues and heart attack risks should always be considered before running, especially long endurances races or races in extreme settings.

        ACE-Inhibitors (lisinopril, ramipril, enalapril, etc.) - Great for protecting the kidneys from the affects of long term high blood pressure but can cause the kidney to retain potassium and creatinine.  Build up of potassium and creatinine can cause issues for runners.  Proper hydration can help minimize some this issues as urination will eliminate them, but do be careful particularly in long and hard running adventures.

        Beta blockers (metoprolol, propranolol, atenolol, etc.) - Generally speaking these medications can limit a person's heart rate and cause them to feel "run down" especially when starting them.  Dizziness may happen when exerting one's self on these medications.  These medications improve the heart's efficiency but, since they limit the heart rate, may leave users feeling limited or like they are redlining when running.  There are some reports that show propranolol might be an outlier of this group, particularly for endurance athletes, but more evidence may be needed.  Running with these may be difficult, sticking to a slower pace, to keep the heart rate down, would be advisable.  All beta blockers are also considered performance enhancers as well, so let the proper authorities know.

        Calcium channel blockers (amlodipine, diltiazem, verapamil etc.) - Some drugs in this class can work like the previously mentioned beta blockers and lower heart rate, however there is more evidence that they may be safe in exercise. For all intents and purposes, very similar to the issues beta blockers have with running, amlodipine being a bit of an outlier and can cause some peripheral edema due to it's unique way of working compared to other calcium channel blockers

        Diuretics (hydrchlorothiazide, spironolactone, furosemide, etc.) - Diuretics can cause problems for runners due to the effects they have on electrolytes and hydration, both of which are key to running. Most of these should be avoided while running.  Runners tend to have were kidney issues occur, as well as things like edema.  Holding these for after a race may be advisable for some, but definitely worth checking with your medical provider based on your exact situation.  All diuretics are considered performance enhancing so let proper authorities know.

Statins (atorvastatin, Lipitor, simvastatin, Zocor, etc.) - Many people worry about the affects this class of medications have on their muscles due to horror stories they have heard.  They are generally safe to use while running, especially since they minimize the chance of having a heart attack or stroke.  Statins due increase the chance of rhabdomyolysis, which is a concern for extremely intense runs or in longer runs. One interesting thing about these is that their beneficial effects for most people are due to their long term use, therefore they may be able to be stopped in the harder parts of training or racing to minimize the recovery periods and risk of rhadbomyolsysis, BUT that should be discussed with a medical provider.

ADHD medications (amphetamine salts, Adderall, Vyvanse, methylphenidate, Concerta, etc.) -  These medications are all considered performance enhancers.  This class can also elevate the heart rate and blood pressure, so should be used in caution in strong aerobic activities like running.  There have been studies showing that running is good to minimize the need or dose of these medications.  These medications may also be stopped prior to long periods of exertion, which would help minimize the cardiac risks, although this may not be the best option for all. 
Many runners I know who take ADHD medications claim they don't use them on race day and do just fine. 
They state the run itself is easy enough to focus on and they don't have a need for these medications on these runs.



I will admit that I did not cite all of my sources for this blog post, but they are all good sources and inline with what I know professionally as a pharmacist (and non professionally as a runner).  There would literally be hundreds of citations that would take me forever to post.  Please rest assured that I double checked anything I was even the least bit questionable on and want to keep my professional reputation in the highest regard.


Do you have any questions for the pharmacist? 😏

Thanks for reading.


Tuesday, April 3, 2018

March Madness - Final Rounds

With March fully over, it's time to wrap up the March Madness of running!  Below are the final rounds and the winner.


Round 3



1. Scott Jurek vs. 2. Roger Bannister

Winner: Scott Jurek

Bannister set one of, if not the, gold bar in running.  His credentials and ability to give back to the sport of running until his recent passing puts him in the stratosphere of running. To this day his 4 minute pace is still basically the US standard for Olympics qualifications in the 1500 meter distance (1500 meters in 3:54:00 is the US standard to make the Olympic trials).  Whenever your record holds its own for over 60 years as the mark everyone knows and aims for, you've done something amazing.

Jurek might not have quite the name Bannister does right now, but several books written by him or about him have changed the running world immensely.  Ultramarathons are now much more common and more people are doing them then ever before.  Jurek's plant based diet has also changed the diet of many runners. As human's continue to push the limits, both of these men will be remembered for what they have done to raise and set records but while Bannister's time will remain one of legendary proportions, Jurek helped launch runners into new unthinkable distances at a record clip.





1. Steve Prefontaine vs. 2. Kathrine Switzer

Winner: Kathrine Switzer

Prefontaine is iconic due to his influence and style.  Prefontaine helped launch Phil Knight's little running shoe company from Oregon to the world, and I think Nike will be around for awhile. Prefontaine is in large part credited with helping spark the running movement in the US, Kathrine Switzer just did him one better by allowing women to run in longer distances.

Switzer's breaking down of the gender barrier is possibly the only thing in this bracket that could have stopped Prefontaine.  While Nike certainly grew due to Prefontaine, there were other factors that helped it more and it would invevitably succeed on it's own right.  Without Switzer, it could have been years or more before women could run marathons.  Given that marathons and half marathons are a near 50/50 mix of women and men these days, I'd say her shadow is more ever present now than ever before.





1. Jesse Owens vs. 3. Dean Karnazes

Winner: Jesse Owens

Sorry Dean, your run stops here.  While Karnazes did help teach people about ultramarathons, and arguably inspire as many people as Jurek, he never set any world records that were heralded by millions around the globe the way Owens did. Karnazes has his wins in some of the toughest races on Earth, but Owens did it on the biggest stage while staring down the Nazi's.




1. Usain Bolt vs. 2. Ann Trason

Winner: Usain Bolt

Ann Trason is legendary for winning so many races and virtually being untouchable, especially among women, in the ultramarathon world.  Her longevity, consistency and times are still unbroken.  She proved in the steps of Kathrine Switzer than women can and will compete with the men.  Usain Bolt is just the best to ever do it, on a bigger stage, with more fans and more influence.  Trason never had a shot at the Olympic golds the way Bolt did, but Bolt is the Lebron James of sprinting.



Round 4



1. Scott Jurek vs. 2. Kathrine Switzer

Winner: Kathrine Switzer

Jurek is actually my personal favorite runner on this list and unquestionable ultrarunning legend.  Jurek's influence is well documented previously and his ability to make ultrarunning appeal to masses is only on par with Dean Karnazes.  While Jurek rarely loses and has even set the one time speed record on the Appalachian trail, Switzer's impact is greater.  Although Jurek would probably beat Switzer in any distance of running, Switzer paved the way for legends like Ann Trason.  Switzer has her wins but becoming a symbol of female power and the ability to overcome edges out Jurek's awe inspiring stories of battling the Tarahumara.




1. Jesse Owens vs. 1. Usain Bolt

Winner: Jesse Owens

Usain Bolt is the Lebron James of sprinters, but Jesse Owens is the Michael Jordan.  Bolt might have more medals and faster times, but he never had to overcome militant racism at the Olympics or unfair racism at home. Owens, an Cleveland, Ohio man like myself, faced it all and won.  It's sad despite all his fame and legendary status, still faced all of the discrimination he did.  Owens had to work other jobs and even race horses to survive, yet was still considered the greatest to ever do it.  A recent article actually compared the two head to head holding for variables and Bolt won, by only one stride. People have claimed that Usain Bolt is decades ahead of his time, so what does that make Owens? Centuries ahead of his time?



Final Round

2. Kathrine Switzer vs. 1. Jesse Owens

Sometimes becoming the greatest runner isn't about speed but the impact and lasting effects of your runs.

This is a tough battle of two very different athletes from different times and exact opposite distances.  Both overcame adversity and both did so for a better cause in a relatively short period.  Switzer still runs today and has written books.  She is unquestionably the most influential female runner. Owens however has several Olympic gold medals, world records and overcame just as much if not more than Switzer did, although he never had to breakdown the huge gender barrier...


Sorry Kathrine, but this was very tough.


Winner: Jesse Owens





Let me know what you think in the comments, retweets or messages.  This was fun for me and I hope you learned something about running greatness along the way!

Use code EGCLE10 to save 10% on registration for the Rite Aid Cleveland Marathon!