Wednesday, October 14, 2009
It should come as no surprise that the anti-doping police never sleep and try to keep athletic competition free from performance enhancing drugs. It might come as surprise that many well meaning physicians may unwittingly harm the reputation of an athlete by practicing good medicine and following treatment guidelines. Such is the case of Fabio Cannavaro, the Italian soccer star, who received a cortisone injection to help decrease the inflammation of an allergic reaction.
When people here the word steroids and athletes, the automatic presumption is anabolic steroids and body building. For most of the world though, steroids equals prednisone or cortisone, medications that decrease inflammation and they are the treatment cornerstone of many illnesses. Patients with asthma, emphysema, arthritis and many other diseases are given better quality of life because these medications help control inflammation at the cellular level.
Allergic reactions can be deadly serious. When exposed to something that triggers the allergy, whether it is an insect bite like with Mr. Cannavaro’s bee sting, a food product or a chemical in laundry detergent or perfume, the body begins producing mast cells that contain histamine. Histamine that is released in the body can be an inconvenience if it causes hives that itch. But it can also be a disaster if that swelling occurs in the lungs, narrowing breathing tubes causing wheezing and shortness of breath. If the swelling occurs in the mouth, the tongue can enlarge making it difficult to swallow or breathe in. These are true emergencies, sometimes referred to as anaphylaxis.
There is a stepwise treatment of allergic reactions. Itching and hives are often treated with an antihistamine like diphenhydramine (Benadryl). If it’s a little worse, a corticosteroid like prednisone or prednisolone may be used. The initial dose may be given intravenously (IV) or intramuscularly (IM) and then pills may be given for a few days. When anaphylaxis is treated, the kitchen sink is thrown at the patient to help prevent shock and death. Intravenous medications are given quickly and can include Benadryl, Zantac (a different type of antihistamine often used for heartburn), Solumedrol (a steroid) and sometimes epinephrine or adrenaline.
If the patient is lucky the medications will work and the inflammation associated with the allergic reaction will be calmed and the patient will gradually recover. Sometimes things get worse and people need to have their hearts and lungs supported to maintain breathing and blood pressure.
Prednisone, and medications like it, is the mainstay of many treatments and physicians prescribe them without thinking that perhaps their athlete patient may run afoul of the law. Unfortunately for Mr. Cannavaro, these types of medication are included on “The List” that is published each year by the World Anti-Doping Agency (http://www.wada-ama.org/rtecontent/document/2009_Prohibited_List_ENG_Final_20_Sept_08.pdf). It’s not that he can’t have the medication in his body, rather, there has to be forms filled and filed to explain the reason. And that may be why he is playing for Italy again this week
As usual, the work of the physician, trainer and athlete isn’t done until the paperwork is done. As the Italian team physician was quoted as saying, the case was purely “bureaucratic”