Journal of Pharmacy Practice

The most inactive Americans are over the age of 65. Age-related physiological changes affect the ability to perform certain types of exercise. The cardiovascular and musculoskeletal systems are directly affected by these age-related changes, resulting in the modification of an exercise regimen. Individualized exercise programs depend on comorbidities, which limit the risks and maximize the benefits of exercise. Evidence supports the benefits of wellness exercise programs. The type of exercise beneficial for an individual is dependent on his or her overall health, disease state, and medications. Age-related physiological changes lead to the development of a wide range of chronic disorders that are often mistakenly assumed to be part of the normal aging process. The purpose of this article is to review the age-related physiological changes associated with exercise, the benefits and risks of exercise, and the wellness guidelines for initiating exercise in an individual over 65 years old. Included in this article is a discussion of the specific exercise guidelines for osteoarthritis, osteoporosis, obesity, psychological health, and diabetes mellitus.

During the 2002 Olympic Winter Games at Salt Lake City, Utah, more athletes tested positive for doping than in all previous Olympic Winter Games combined. Approximately 4% (96) of all registered athletes were tested in the out-of-competition testing phase. There were no positive urine specimens. During the in-competition urine doping control program, 559 urine specimens were tested. There were 2 specimens positive for nandrolone and 1 specimen positive for methamphetamine. During the testing of endurance athletes for erythropoietin and related substances, there were 3 specimens positive for darbepoetin, a substance related to erythropoietin. These results signal an increased awareness of new scientific technologies and a resolve to use these procedures for antidoping efforts. The World Anti-Doping Agency is positioned to take a leadership role in harmonizing the antidoping efforts of the international sport federations, the national Olympic committees, the International Olympic Committee, the national sport governing bodies, and national antidoping agencies.

The use and effects of selected performance-enhancing drugs and nutritional supplements are reviewed. Recent sports medicine studies are mostly double blind and placebo controlled but contain relatively small sample sizes. Their data appear reliable and are reported in reputable journals. Definitions and methods used in sports medicine are provided to enhance the understanding of this literature. The use of performance-enhancing substances is probably under-reported. Anabolic-androgenic steroids are reportedly used in 0% to 1% of women, 0.5% to 3% of high school girls, 1% to 5% of men, 1% to 12% of high school boys, and up to 67% of some groups of elite athletes. The use of combinations of performance-enhancing substances is common. Carbohydrate loading, adequate protein intake, creatine, blood doping, and erythropoietin (epoetin alfa) appear to enhance performance. Anabolic-androgenic steroids enhance performance, but health risks limit their use. Growth hormones and β₂ -selective adrenergic agonists may enhance performance, but additional studies are needed. Androstenedione, caffeine, amphetamines, and nonprescription sympathomimetics do not appear to enhance performance. Performance-enhancing drugs have shown some benefit in diseased patients with malnutrition and/or decreases in physical ability. Pharmacists and other health care providers have opportunities to improve the understanding, use, and monitoring of performance-enhancing substances.

This article reviews adverse effects of and the difficulty of attributing toxic effects to selected drugs and dietary supplements that purportedly enhance athletic performance. On surveys estimating the extent of performance-enhancing drug use, 5% of high school students indicated anabolic-adrenergic steroid use, and approximately 28% of collegiate athletes and 5.6% of middle and high school athletes admitted creatine use. Many adverse health effects from the abuse of androgenic-anabolic steroids and androstenedione (a prodrug) are exaggerations of excessive testosterone on hepatic, cardiovascular, reproductive, and behavioral functions that can produce permanent changes. With creatine use, nausea, vomiting, diarrhea, elevated serum transaminase concentrations, hypertension, fluid retention, muscle cramping, and muscle strains have been reported. Ephedra stimulates adrenergic receptors, leading to tachycardia and hypertension, with central nervous system effects of anxiety, tremor, and hyperactivity. From 1997 to 1999, 10 people died and 13 suffered permanent disabilities due to ephedra. γ-Hydroxybutyrate and several prodrugs (γ-butyrolactone and 1,4-butanediol) can produce alternating agitation and coma, amnesia, hypotonia, ataxia, nystagmus, tremors, bradycardia, respiratory depression, and apnea. Although γ-hydroxybutyrate abuse began as a bodybuilding aid, most serious adverse effects are from acute overdoses. Adverse effects from performance-enhancing drugs do occur, but their extent and frequency are unknown.

The well-documented benefits and popularity of sports and fitness have led to an increased demand for products that not only replace sweat losses but also provide fuel for continued high-intensity metabolic demands. The twin risks of hypohydration and hyponatremia can lead to morbid and even fatal outcomes if rational replacement regimens are not followed, especially in endurance athletes and during hot or humid conditions. The avoidance of these complications of physical activity with oral replacement products has been documented primarily in high-impact, prolonged-duration events. Replacement fluid should contain water, sodium, and perhaps potassium to avoid overhydration-induced hyponatremia. Carbohydrates are added if muscle exertion is to continue for prolonged periods (>60 minutes in duration). The overuse of oral replacement products may yield the dilution of serum and intracellular electrolytes, hyperglycemia, and gastrointestinal distress. Baseline hydration and glucose status should be optimized before activity, and alterations in the amount and type of fluid ingested may be required for special populations such as children and individuals with chronic disease.

Participation in sports-related activities increases the risk for acute injury to soft tissues. In adults, the sites most often affected include the ankle, knee, and wrist joint structures, along with the muscles of the back and extremities. The subsequent inflammatory response to tissue damage results in pain and swelling, which limits mobility. A thorough patient assessment is required for accurate diagnosis and provides a guide for appropriate treatment. Initial management is based on the principles of basic first aid: rest, ice, compression, and elevation. Pharmacological therapy can also be used to achieve pain relief and improve mobility. There are few well-controlled studies addressing the pharmacotherapy of acute soft tissue injury, but clinical experience with nonsteroidal anti-inflammatory drugs is extensive. Both traditional and nontraditional therapeutic approaches are discussed.

Exercise-induced asthma is a common complex pulmonary disorder associated with a diagnosis of chronic asthma including cough, dyspnea, wheezing, and chest tightness that affects millions of patients worldwide. Exercise-induced asthma patients are frequently inhibited from participating in physical activities because of the degree of pulmonary dysfunction. Pharmacological agents, the cornerstone of treatment for exercise-induced asthma, improve pulmonary function and quality of life. Short-term and long-term adrenergic β₂ sympathomimetics, mast cell stabilizers, leukotriene receptor antagonists, 5-lipoxygenase inhibitors, and corticosteroids are commonly used. β₂ sympathomimetics are the most potent bronchodilators and are considered the first drug of choice. Inhaled corticosteroids and mast cell stabilizers assist with the reduction of airway inflammation and response to exercise and are generally added in combination with β₂ sympathomimetics for maximum efficacy. Leukotriene receptor antagonists and inhibitors may be alternatives for patients who do not receive adequate prophylaxis with inhaled β₂ sympathomimetics, corticosteroids, or mast cell stabilizers. Pharmacotherapeutic regimens must be tailored to meet the specific needs of patients. However, other factors must be considered, including side-effect profiles of the agents, cost, medication compliance, drug-drug and drug-disease interactions, insurance limitations, improvements in pulmonary function parameters, and understanding of the disease.

Altitude-related illness is a frequent cause of morbidity and occasional mortality among recreational sports travelers in the United States and throughout the world. High-altitude illness describes the cerebral and pulmonary syndromes (acute mountain sickness, high-altitude cerebral edema, and high-altitude pulmonary edema) that can occur in unacclimatized persons ascending too rapidly to high altitude. The pathogenesis of these syndromes is primarily hypobaric hypoxia that causes compensatory changes in the brain and lungs, resulting in hyperperfusion of microvascular beds, increased capillary pressure, and a microvascular leak with resulting edema and a characteristic constellation of symptoms. Prevention and treatment involve education about rate of ascent; diet; alcohol intake; physical activity; oxygen; hyperbaric chambers; and pharmacotherapy, including acetazolamide, dexamethasone, nifedipine, and salmeterol in selected circumstances.