Understanding the Impact of Common Medications on an Athlete’s Physiology and Training 

Dr. Jeff Sankoff, the “Tri-Doc,” walks us through a list of medications and their impact on athletes to better understand risks, necessary training adaptations, and how to better communicate with your doctor.

FTL episode 312 with Jeff Sankoff

Medications, often coined “drugs,” have historically carried a negative connotation in cycling, running, and triathlon – and for good reason. For too many years, athletes have abused pills, capsules, and injections for the sole purpose of gaining an advantage over their competitors.  

However, the fact is that everyday athletes are using medications to treat infections, prevent heart disease, manage their blood pressure, and address other health conditions. Even though these medications may not be enhancing performance there are still important considerations that athletes need to be aware of – how these medications may impact their zones, whether they’re “legal” or if a therapeutic use exemption is necessary, and the list goes on. 

Joining the show today is Dr. Jeff Sankoff. He’s an emergency medicine physician, athlete, and coach known as the “Tri-Doc”. We tap into his incredible knowledge of not just medicine, but also physiology, athletes, and competition. There are many things an athlete should be aware of when taking medication while training and racing.  

We cover numerous aspects of medication use that an athlete should understand such as safety of NSAIDs during exercise, training adaptations that may be necessary, adverse effects ranging from imbalanced gut microbiome to risk of tendon rupture, impact of certain medications on heart rate and lactate levels, and especially important, how to communicate with your physician about taking medications as an athlete. The “Tri-Doc” walks us through a variety of medications, including and not limited to beta-blockers, antibiotics, diuretics, statins, NSAIDs, and more. 

So, let’s learn a little more about the ins and outs of medicine and endurance sports before you pop that pill… and then, let’s make you fast

Episode Transcript

Rob Pickels  00:05

Medications. Drugs. These words have a negative connotation in cycling, running and triathlon and for good reason. For too many years athletes have abused pills, capsules and injections to get an advantage over their competitors. However, the fact of the matter is that everyday athletes are using medication to treat infections prevent heart disease, or manage their blood pressure. Even though these medications may not be performance enhancing, there are still important considerations that athletes need to be aware of how do they affect your zones? Or are they legal? Or do they need a therapeutic use exemption?

Rob Pickels  00:41

Joining me today is Jeff Sankoff. He’s an emergency room physician, athlete and coach known as the try doc, we tap his incredible knowledge of not just medicine, but also physiology, athletes and competition. So let’s hear a little more about the ins and outs of medicine before you pop that pill. And let’s make you fast. Hey, listeners, welcome to another episode of fast talk. This one’s a little bit different. I don’t necessarily have Trevor Connor sitting across from me. But I do have Jeff sand cough who is the try doc? That is right. Awesome. And the reason for that is Jeff is an emergency room physician. He’s an athlete, he’s a triathlon coach, he’s on his way to being a cycling coach. That’s right. And so he’s a pretty good guy. For our episode today, we’re going to be talking about medication, things that you have to take your doctor prescribed to you, maybe some over the counter stuff. And ultimately, what I want to talk about though, is a little bit different. Just some considerations that you ought to have with the medication that you’re taking this is not to say you should or shouldn’t take it. If your doctor has you on medication, it’s probably for a good reason. And in any changes you should probably definitely discuss with your doctor. But as sports scientists, as athletes, we want people to be aware of maybe just, you know, some considerations how your heart rate might change how your recovery might change things of that nature, so that you can ultimately be the best endurance athlete that you can. Jeff, you want to start out real quick. Just let’s hear about your background. Tell us about being a doctor. Tell us about being a coach and an athlete.

Jeff Sankoff  02:12

Yeah, absolutely. I came from Montreal, Canada. Born and raised, I went to medical school there. And when I finished my critical care training after doing a five year residency in emergency medicine, and then a two year fellowship in critical care, I found myself at a little bit of a crossroads, I call it my auntie dufrane moments, which was get busy living or get busy dying because I was very much out of shape very much overweight, and with a family history of a lot of heart disease and didn’t want to go down that road and made a decision that I had to get in shape. And so I started eating better doing some exercise and over a period of four or five months started to lose some weight. And one of my colleagues noticed and she said to me, what have you been doing? I just changed your life. I had been doing some running and some cycling, and she said, Well, you know, you really should do a triathlon and I laughed because I was like, yeah, no, the only triathlon I knew was Hawaii. And that was not something that interests me. And also I didn’t really know how to swim. Well over the course of dinner, she kind of convinced me that was something that I should think about. And over the next year, I learned how to swim and bought a bike and got a coach and did all the things that you needed to do and did my first triathlon and after that I was hooked. And so for the next 20 years, I just been doing triathlons and getting better at them slowly but surely until finally, I had kids that were old enough to let me train earn in earnest go. Over that time, I had the good fortune to meet some people who were writing or in the world of triathlon magazines and other publications and started writing medical articles for different triathlon publications. And I don’t know just overtime just always love the sport always loved how it changed my life and in 2018 decided I wanted to take the next step. And so I started a podcast, try doc podcast and then started coaching got myself certified by USA Triathlon and Ironman University and I’ve been coaching as tried our coaching ever since then, and actually got myself to that race in Hawaii a couple of times, did you? Yes, I did. First. The first person I called to tell that news was that woman who had first convinced me to do a triathlon and who I said no, no, never gonna go to that race.

Rob Pickels  04:28

So that’s awesome. So you did figure out that swim side of it sounds like eventually. For me, I will say I’m proof that you don’t need to know how to swim to do a triathlon. You just need a wetsuit. Yeah, definitely helped. saved my bacon. That’s for sure. Well, Jeff, I think that you know, today we should start the conversation with something that’s really common for people to take right and that’s over the counter NSAIDs, anti inflammatories, pain medication that you might take. And, you know, for me, I was looking into research tear and I’m really interested to hear your take. I was always under the impression that take an NSAID go for a long run, it’s a common thing for people to do. But ultimately, you’re gonna be leading to some deep damage within your body. And and I don’t know that I found strong evidence for that. So I think that I want to start this off with a question of is it safe to be taking NSAIDs while people are out exercising, doing some grueling things, not just a 5k You know, but marathons, ultra marathons, dehydration, all of that working in? Yeah,

Jeff Sankoff  05:31

that’s a great question. And Ted’s account for billions of dollars of sales every year, and they’re a huge boon to the pharmaceutical industry. The acronym stands for non steroidal anti inflammatory drugs, and they comprise a wide variety of different types of medications they include, the first one that was ever found, which was aspirin are acetyl salicylic acid, but have gone on to include much more commonly used ones today, like ibuprofen Naprosyn, which is an approximation, as well as several others. And with any medication that we take every single drug that you will ever encounter, we have to always remember that for any positive beneficial effect that a medication gives us, there’s always the potential for risk. And those risks can be adverse effects that are very minimal. They can be minimal side effects, or sometimes they can be very, very dramatic. With non steroidal anti inflammatories, there’s a second thing that we have to think about, and that is the effect that they have on exercise adaptations. I’m glad you brought that up. So and that’s an important one, of course, is all of us as cyclists we want to always consider is medication that we’re taking actually having an impact on our training. So let’s start first with the risks. The most commonly known risks associated with every nonsteroidal anti inflammatory is gastrointestinal bleeding. So what that means is bleeding from the stomach. We have a large amount of acid that’s formed in our stomach as part of the defense to keep bad things out, but also to help our digestion. And we normally have a defense mechanism that is there that requires prostaglandins. And those prostaglandins help defend our stomach lining against that acid. When we take non steroidal anti inflammatories we actually inhibit an important enzymatic pathway in the formation of prostaglandins. And that actually is why inflammation is decreased with non steroidal anti inflammatories, because prostaglandins are so important for inflammation. Well, it also turns out prostaglandins are important for protecting our stomach lining. So yeah, interesting.

Rob Pickels  07:44

For me, I always assumed that it was the acidic nature of that ibuprofen, or whatever it is, and not this prostaglandin in ambition, and I’m going to share a really silly story. I made a mistake, one time, I was taking a red eye on a plane, and I had a splitting headache. So I wanted to take some Advil, but I didn’t have any water. And I didn’t want to bother the flight attendant or anyone else around me because it’s like one o’clock in the morning. So I just put the Advil in my mouth. And I was like, I’m just gonna go let this thing dissolve. Well, that enteric coating is on there for a reason. And all was well and good until that coding wore off. And I ended up getting like an ulcer on the side of my mouth, I’m assuming from the acidity of this medication, and I quickly spit it out because there was no way I was swallowing it at that point. Anyway, I say all of this, because I had assumed that that was the mechanism that ultimately led to an ulcer in your stomach was the acidity. And so this prostaglandins side of things that is really interesting to me, ya know,

Jeff Sankoff  08:44

it’s the medications that we take are not I mean, even aspirin, which is acetyl salicylic acid is a very, very weak acid, Ginger pH is only 6.4. It was very, very weak when you consider this, the acid in the stomach is actually hydrochloric acid. Sure. And that pH is like two. So when we talk about pH, the lower the number, the more acidic something is, and 6.4 is really not very acidic at all. Most drugs are weak acids. And I think Ibuprofen is one of them. But it’s really, really not very strong acid at all. And it has no major effects on the stomach. As if you just like put that drug on the on the lining of the stomach is not going to do anything. Yeah, the fact that it did something to your tongue is probably just irritation as opposed to any acidity. Yep. That being said, you never want to leave something is both very true. Yeah. Now the prostaglandin issue is the issue. Yeah. So again, non steroidal anti inflammatory all work the same way they inhibit an enzyme called Cox one or Cox two, most of them inhibit both. And that enzymatic? That enzyme is important for forming prostaglandins. prostaglandins work to cause inflammation. If you inhibit that enzyme, you don’t have prostaglandins. You decrease inflammation. You also need prostate gland And then to protect the stomach. So Good bye prostaglandins, good bye defense mechanisms in the stomach, the acid can then cause ulceration. And if that ulceration goes deep enough, it can erode into blood vessel and you get bleeding. So that’s one of the major side effects of non steroidal anti inflammatories, it doesn’t happen to everybody, you have to take a lot of nonsteroidals you have to take them pretty chronically for a duration of time. Yeah, but a lot of people do. A lot of people take ibuprofen on a regular basis without recognizing that it has that

Rob Pickels  10:29

effect. Now, if I’m taking ibuprofen for a couple of days in a row, I have a little SI joint issue that bothers me Advil seems like it clears it up pretty well. I can end up with some stomach discomfort, where it just I’ll eat something it doesn’t quite sit right. Is that associated with what you’re talking about? Is

Jeff Sankoff  10:46

it is that’s that’s gastritis. Gastritis is just inflammation of the stomach lining, and it’s the first step in that process towards ulceration. There you go. Now you recover from that if you stop taking the anti inflammatory, then you’ll be fine. But if you continually take anti inflammatories and get that irritation of your stomach, it’s suggest that you have to be careful, right?

Rob Pickels  11:07

And this is something endurance athletes, right? They’ll feel a little sign, they’ll feel a little something is off, and they’ll just keep charging forward as if nothing goes wrong until the situation blows up.

Jeff Sankoff  11:17

Unfortunately, we are notorious for that. Now,

Rob Pickels  11:20

I will say it was hard for me to find Jeff Actually, it wasn’t hard for me to find Jeff Jeff was recommended as a guest on the show from the slow twitch forums. But what was important to me was that I had somebody to talk to today who was an endurance athlete who got it from that side, not necessarily just a doctor or pharmacist really knowledgeable. And so I’m glad that you’re bringing this insight to the conversation. Well,

Jeff Sankoff  11:44

the second potentially bad side effect with nonsteroidals is one that doesn’t cause so many symptoms. And that has to do with renal impairment or impairment of kidney function. Okay. So, that prostaglandin issue. Well, prostaglandins are also important for how the blood vessels within the kidneys react, it would be getting into the weeds for me to really get into this in great detail. Suffice it to say that our kidneys are exquisitely sensitive to blood flow. That is because they are very, very metabolically active. And the second you deprive the cells within the kidney of oxygen to a certain degree, they start to die. You need prostaglandins to regulate blood flow in the kidneys. And when you decrease the amount of prostaglandins around because you’re taking non steroidal anti inflammatories, you can jeopardize blood flow to those cells in the kidneys and result in something called acute tubular necrosis. And eventually, renal failure in a state of dehydration particularly, taking nonsteroidal anti inflammatories increases the risk of renal failure. And as we all know, when we’re exercising, especially in the heat, we are almost always invariably no matter how well we tried to rehydrate, we end up in a dehydrated state. And as a consequence of that, the potential for getting renal impairment when taking non steroidal anti inflammatories, when exercising is significant, and has to be considered. Even if you take nonsteroidals after exercising, if you haven’t rehydrated adequately, there is that risk? Interesting. We don’t know how common it is. It’s not like I see patients coming into the emergency department because they went running that day, they took ibuprofen and ended up in renal failure. It doesn’t happen to that degree. But we know it’s a risk. We know it’s possibility, and therefore always counsel my athletes who I coach, because I have several who come to me and they say listen, I like to take an ibuprofen after the first half of the marathon, because it helps me get through the second half with the last pain and I tell them do not do them, right, because the risk is simply too high. And it’s not worth the risk.

Rob Pickels  13:55

And that’s what I was going to ask is there a safe amount to take you know, let’s say somebody goes based on the package recommendations. I know myself, the listeners of the show, know that I have some some long term kidney issues that are autoimmune related. So I stay away 100% Because of this, but it is really common for people to be taking these NSAIDs while doing especially marathons or Ultra is even more so. Is there a safe amount or is this like a you’re playing with fire as soon as you take a minimal amount? I

Jeff Sankoff  14:26

can’t in good conscience provide a safe amount because because what might be a safe amount for one person is not going to be safe for somebody else. So it there’s no way for me to say that there is truly a safe amount the safe amount is zero when exercising and using ibuprofen after exercise for aches and pains is generally considered safe as long as you stay within the recommended dose and a lot of people go way over the dose because let’s face it, ibuprofen does have a pretty well established safety profile and We know that you can take large doses, but the higher the dose, the more likely the side effects of stomach and kidney problems. So you really should stay within the recommended doses and you want to make sure you’re well hydrated is

Rob Pickels  15:12

there. Can I ask is there like a washout period? You got a big trail race coming up on Saturday, but your knees bothering you. So you’ve been taking some ibuprofen? Is there a general recommendation? Like, hey, you should be off of it by Thursday? Give it a day wash out? Or is there nothing like the drugs

Jeff Sankoff  15:29

are pretty well metabolized in a pretty predictable manner, when we talk about these drugs are dosed every four hours. So when we talk about a four hour dosing, that usually means by eight hours, they’re completely out of your system. Okay,

Rob Pickels  15:42

so even stopping the day before, it’s probably out of your system on race day, which means you’re likely at no increased risk for an acute kidney injury. Yes, that’s correct. Okay, awesome.

Jeff Sankoff  15:53

I do want to return to the the other thing about NSAIDs, and that is their effect on adaptation to training, do it. When you go out and train hard, you finish your training session, you often feel sore, you know, you’ve worked out because you can feel the effects on your muscles. Those effects are inflammation, they’re inflammatory effects, we want that inflammation, because what’s happening is you’re causing almost micro damage within the muscle. And the repair mechanism is basically the process of inflammation. It involves the inflammatory cells rushing to the damaged muscle areas, it involves the removal of the different damaged fibers and the rebuilding of those fibers in a stronger, more effective muscle cell that will be able to handle the stress load that you just gave them more effectively. If you interfere with that process by giving an anti inflammatory medication, you decrease the adaptation in those cells. And it has now been shown in several studies, that taking anti inflammatory medications during the adaptive phase of training, specifically, that phase of training where you’re really trying to build, you can actually decrease performance right now, this is true for younger athletes, athletes in their basically teens, 20s 30s 40s. Once you get into my age group 50s 60s We tend to live in a heightened stage of inflammation, okay, that is to say that as you get older, your inflammatory processes aren’t as well checked, and you tend to always be in a more inflammatory process always adapting? Well, it’s the problem is, is that that inflammatory process tends to do more harm than good. And in that case, taking anti inflammatories may actually be a little more helpful interest. And there’s a lot of evidence now coming out that says, Oh, actually, if you have some delayed onset muscle soreness after doing exercise, taking into anti inflammatories in your 50s and 60s, again, with the caveat that that’s also a higher risk for renal and stomach stuff. That actually is probably not so bad, but it may help. Yeah,

Rob Pickels  18:00

it’s interesting. I think that oftentimes we see athletes undergo strategies that help them train more. If I take this and said this ibuprofen, this is Tylenol and NSAID.

Jeff Sankoff  18:10

So Tylenol is not an ensay. Tylenol works completely differently, it has no effect whatsoever on the COX enzymes, it does not affect the stomach or the kidneys, people will

Rob Pickels  18:19

take medications like this, to decrease soreness so that they can train more so that they can get better adaptation. And it often is important that we’re recommending or reminding maybe as the better word, hey, it’s not necessarily about training more. It’s about improving your adaptation to that work that you’re doing. That’s efficient training, whether that’s the supplements you’re taking or the intervals that you’re doing or the amount of base volume you’re doing. And we have had this conversation before in regard to antioxidants, right, taking very large amounts of vitamin C, or NAC and acetyl cysteine can also decrease it through similar mechanisms, the adaptation that you have to that bout of exercise, right,

Jeff Sankoff  18:59

it comes back to what I said at the beginning, everything we take has a risk benefit profile, and we always have to think you know, we want to stay on the benefit side without getting into the risk side as much as we can. And I just want to mention about Tylenol, Tylenol, pretty safe drug but very dangerous. The second you step out of the recommended dosing, so please be careful with Tylenol.

Rob Pickels  19:22

Right and that’s a high high incidence of very significant liver injury when you take too much Tylenol. Yeah, it’s

Jeff Sankoff  19:29

the number one cause of liver transplant and acute liver failure. Tylenol remains number one.

Rob Pickels  19:38

Yeah. So real quick, kind of while we’re talking about Tylenol, do we have any of these other let’s say an endurance athlete is taking Tylenol within the recommended dosage. Are there any relief considerations with that as a particular medication like we talked about with the NSAIDs?

Jeff Sankoff  19:50

Yeah, Tylenol doesn’t seem to impair the adaptation phase of training so it can be used for pain control. There were some people who used to think that taking Tylenol John During an activity like a race, that it might help, because Tylenol has pretty good effects on controlling temperature. You know, we take Tylenol to decrease a fever, for example. And people used to think, Well, maybe if I take Tylenol during a race, it’ll help me keep my core temperature down. And studies have shown that it does not do that. And it doesn’t seem to impair performance. But it doesn’t help performance either.

Rob Pickels  20:19

Yeah, sure. And so if anybody is out there doing some research on their own, like I encourage everybody to do, you might also see the term parsimony tall, which is Tylenol as well, but by another name. Yeah,

Jeff Sankoff  20:29

it’s just how it’s called in the UK, the UK. Yes.

Rob Pickels  20:35

Before we take our first break, let’s hear from Brady Homer who has another drug that can blunt adaptation to exercise.

Brady Holmer  20:42

Metformin seems to blunt adaptations to exercise training. And this is kind of become popular because Metformin is kind of quoted as being this maybe longevity drug because it’s going to promote, you know, healthy metabolic health and promote maybe a healthier lifespan. But there have been studies showing that exercising while on Metformin can blunt some of those beneficial adaptations to exercise. So I think people should be wary of if they’re using Metformin, whether they’ve been prescribed it for diabetes, or maybe they’re experimenting with it as this whatever longevity jog, or however you want to phrase it, they should be aware that it can interact with exercise and may limit some of the adaptations you’re getting from that.

Trevor Connor  21:22

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Rob Pickels  21:43

Jeff, that was an incredible opening segment. You know, we started out with NSAIDs, which is probably the most common thing that people take, I’d love to jump over to some heart based medication that are some of the most commonly prescribed medications. And that is antihypertensives blood pressure medications and also statins. Is there one that we want to start with first?

Jeff Sankoff  22:04

Why don’t we start with blood pressure just because that’s more common than statins? Yeah,

Rob Pickels  22:07

certainly. You know, I think that there’s a lot of athletes who are out there. I’m one of them. I’m 42 now, but I’ve been hypertensive for a few years. Seems like it runs my family. My mom was always hypertensive. And so I’ve been on blood pressure medication. And you know, it’s just interesting to me, a lot of people are surprised by that 42 year old on blood pressure medication does a lot of endurance work that’s supposed to be great for your blood pressure. And so it was important to me that we talked about this because so many people out there, there are so many athletes who are on blood pressure medication, and I love to peruse things like the TrainerRoad forum, the fast talk forum, gotta plug our own slow twitch. People are always asking questions about these blood pressure medications. And I’m not sure if there were some that you wanted to talk about. But there are two classes that I really wanted to talk about, and that’s diuretics and beta blockers. Yeah,

Jeff Sankoff  22:59

those are definitely among the more common ones, their blood pressure medications come in various classes. There are the two you mentioned. There’s also calcium channel blockers. ACE inhibitors. Ace stands for angiotensin converting enzyme inhibitors. There are the RM ARBs. That’s the angiotensin receptor blockers. So there are various classes, but I think you’re right beta blockers and diuretics are going to be the ones that are probably have the most impact on endurance athletes. And and they’re very common, definitely, just to go back to your comment about how you know you’re younger, and you’re on antihypertensives. There’s a reason more and more people are on these medications. Now, one of those reasons are that the guidelines for starting antihypertensives have changed in the last five to 10 years. And so the upper limit of what we consider normal has changed. It used to be 140, over 90, and that changed recently to 130 over 90. So that gives a kind of a different threshold for when people are going to be started on medications and laugh at

Rob Pickels  24:06

130 overnight.

Jeff Sankoff  24:09

And you also have to put this into context with family history and all kinds of things. But but we know that blood pressure is a silent killer, it is a major determinant of heart attack and stroke and getting blood pressure under control can have really, really important long term benefits. So we definitely want to take care of that. diuretics are generally considered a first line medication for many people. It depends a little bit on different characteristics of the patient, things like that. But the reason is, is because they tend to have less potent effects and less side effects. And the most common one that’s used for blood pressure controlled is a medication called hydrochloric biocide. It basically causes salt wasting in the kidneys and lowers blood pressure simply by just decreasing Overall blood volume, but it also seems to have some effects that we don’t really understand kind of low hand-waving and magic, like

Rob Pickels  25:06

a lot of medication. It seems like he’s like, we think this is how it works, but I don’t know it does what it does.

Jeff Sankoff  25:10

Yeah, because there are other medications. Like for example, there’s a medication called Lasix, which is a much more potent salt wasting medication, and it doesn’t really have any effects on blood pressure. So we’re not totally sure how thiazide diuretics work to decrease blood pressure, but

Rob Pickels  25:24

it does when you say salt wasting, can you explain that a little bit more? Yeah, so

Jeff Sankoff  25:28

those diuretics work on an area in the kidney that prevents the reuptake of sodium. So our kidneys do a variety of things, but one of the most important things they do is manage our total body water. But our kidneys don’t do a great job of actually handling water. Instead, they do a great job of handling salt, and water follows salt. So when we need to hold on to water, we just suck up all the salt that we filtered out, and water will follow it. And so the kidneys do a great job of just handling salt, but different types of diuretics, they block one of the channels that is involved in the reuptake of salt. And by doing that, we lose more salt, and we also lose more water.

Rob Pickels  26:12

So when we’re losing salt, I think that that begs an obvious question from me. athletes that are taking this Are they at increased risk for something like a hyponatremia, or increased rates of dehydration,

Jeff Sankoff  26:24

it’s more dehydration, because sighs I diuretics are not potent diuretics. As I mentioned, Furosemide, which is called a loop diuretic works much more profound. And that’s the lace. Exactly. Yeah. And that that is the loop diuretics are profound diuretics, and you’ll lose huge copious amounts of salt and water. Those are diuretics will increase urination, they will increase salt and water loss, but it tends to be matched. So you’re not losing water in excess of salt, which would lead to things like hypernatremia, and you’re not losing salt in excess of water, which would lead to hyponatremia. So you tend to lose them in a balanced manner. But you are losing more than you would normally. And so yes, if you are on a side diuretic, you need to be cognizant of that. And most people who are on it, usually they they noticed some increased urination for the first couple of weeks. And then things kind of get into a balance, and they tend to not have as much of a problem. Sure. But everybody’s different. And it’s impossible to predict

Rob Pickels  27:18

now. Now as somebody is settling into this lower total body water, right, they’re gonna have less circulating blood volume, I assume, right. And so that’s probably going to what increase is, do we see an increase in sub max heart rate are people’s exercise zones going to be changing at all, generally

Jeff Sankoff  27:36

not because again, our bodies will always fight for what’s called normal stasis. So if we take a medication that kind of sets off a process where we start losing water, we have other processes that are going to fight to restore that our bodies are always looking for this balance. And even though the medication is going to tip us over a little bit, we have other processes that are going to make us thirsty, or that are going to make us crave salt, and we’re going to try and get back into some kind of state of balance. And, and like I said, those diuretics are not that potent. And so we will, our bodies will win that battle. So most of these athletes will get to a point where they’re actually usually MC, meaning they’re at a normal body volume. However, they’re going to be more prone to getting a little bit more dehydrated faster, because of the diuretic effect, because while they’re exercising, the diuretic is still working, whereas yours and my kidney would, as we start to get dehydrated, yours and my and my kidney are going to act in a way to hold on to salt more efficiently. A person who’s on a diuretic is not going to do that, and therefore they’re going to be a little more prone to getting dehydrated quicker, right? So that’s where they have to be careful when they’re exercising. They just have to get on their fluids and their electrolytes quicker.

Rob Pickels  28:48

Certainly. Now what’s really interesting in my opinion about this diuretic conversation is there’s a relative lack of negativity associated with taking with this right, your cardiac output isn’t necessarily changing in a meaningful way. There aren’t necessarily other systemic effects that you have to be worried about. But as far as I know, and I’m going to encourage everybody to check this, especially if you’re on these medications, all biocide, diuretics are banned by water because of their masking ability, right? If somebody is taking a banned substance and you take a medication that increases your urine output, then you may be able to mask that banned substance that you are taking. And a great resource for people to be looking into is called the Global DRL. It’s a website that you can put your your sport, how you engage with the sport, whether you’re an athlete, a coach and official, your nation of purchase, and then the medication that you’re taking. And it will tell you is this band in competition out of competition and so anybody, even if you’re taking medications that have nothing to do with what we’re talking about today. I recommend that you look into you know, for all competition, but especially people where you might might fall under a usado or a water situation, you really need to know and be aware of this resource. Yeah,

Jeff Sankoff  30:06

and the tee up process is not complicated and not that difficult. And you can get a therapeutic use exemption for blood pressure medications quite easily.

Rob Pickels  30:16

Very nice. Hey, can we jump over to the other blood pressure medication, the beta blocker? Yeah,

Jeff Sankoff  30:20

of course. And just to give a brief rundown beta blocker refers to a specific receptor in our body called the beta receptor, there are two of them beta one beta two, the beta one receptor is found principally in our heart, the beta two receptor is found in our blood vessels and also in our lungs. So asthmatics take a medication that is a beta two agonist, so it is the opposite of a beta blocker. It is actually an agonist as the opposite of a blocker is something that acts on the receptor, and beta two agonists like albuterol, work on that beta receptor to cause Bronco dilation or the opening of the airways, so works very well for as a beta blocker, conversely, works to block those receptors. So asthmatics can’t take beta blockers, it causes problems for them. But non asthmatics can take them because what it does is it, it blocks the beta receptors in the heart, so it slows down the heart, but it also blocks the beta receptors in the smooth muscle of the peripheral arteries. And that’s how it works on blood pressure. So it’s doing two things. Number one, it’s decreasing the force of contraction of the heart. And number two, it’s opening up the blood vessels in the periphery, allowing for a decrease in blood pressure on both hands, because blood pressure is determined by the force of cardiac contraction, but it’s also determined by how much squeeze there is on the blood vessels in the periphery. And beta blockers work much more effectively than die diuretics to decrease blood pressure. Yeah,

Rob Pickels  31:49

certainly, you know, as far as I know, beta blockers are one of the earlier antihypertensives. Right. And so I think that they’re still pretty commonly prescribed for individuals, regardless of whether or not they’re athletes, as opposed to maybe some of the newer, more selective things like you had mentioned before the calcium channel blockers, the ARBs, the ACE inhibitors, but the beta blocker, I think, is something that we certainly have to talk about, because it is decreasing this activity, we can see some profound changes on blood pressure, but also profound changes on things like heart rate.

Jeff Sankoff  32:20

Yeah, and the reason beta blockers are still widely prescribed is because they’re incredibly effective. They were increasing morbidity and mortality, especially in people who’ve had any kind of primary heart event. So if you’ve had a heart attack before, if you’ve had any kind of dysrhythmia, meaning your heart beating in a chaotic pattern, atrial fibrillation, or even any kind of ventricular issues, beta blockers will regulate that and prevent those things from happening again. So beta blockers, really, really effective, really, really positive types of drugs. But as you mentioned, they decrease heart rates, and they decrease the ability of the heart rate to increase as needed during exercise. And one of their major side effects is to limit exercise capacity. And it’s a reason why a lot of people can’t be on them. Because anybody who’s active, may find that beta blockers don’t work for them because they want to continue being active and they just can’t, because the beta blocker restricts their heart rate.

Rob Pickels  33:12

Yeah, I think I’ve seen numbers of decrease in heart rate up to about 30%. Right. And so if you’re normally used to exercising at 150 beats per minute, then you might have a hard time getting close to 110 at that point in time. And you know, that decrease in cardiac output and likely vo two Max associated with that is probably going to severely limit exercise performance. But, you know, as you mentioned, there are people who have gone through events, especially cardiac events, where this is an amazing medication for what you have. And unfortunately, you might have to live with this limitation. But Jeff, you know, can I ask, What should people be looking for if they are taking a beta blocker? And what should the conversation be with their doctor to maybe end up on a drug that’s a better fit for them in their lifestyle? Yeah,

Jeff Sankoff  33:59

it’s risk benefit, right? Just like I said, with the NSAIDs, you have to consider what your profile is and what you want. I had a hip surgery, I had a reconstruction of basically a shredded labrum and I went back to my orthopedic surgeon after everything was said and done. And I said, Can I go back to training for an Ironman? And he said to me, you know, I never see athletes who run 10 K’s? And I said, okay, but can I go back and doing an Ironman? And he was implying, I know that he was lying. And we went back and forth for a little while. He said to me, finally he said, Look, we didn’t do this operation for you to not be able to do what you love. So you have to make the decision about whether or not you want to take the risks of doing what you love, and potentially have to come back and see me again versus doing what I’m telling you you can do, but potentially not enjoying what you enjoy. And it’s the same thing with beta blockers. You may go to your doctor and say listen, this beta blocker is restricting me from being able To climb, Flagstaff in the time that I used to be able to do it. And you know, your doctor may say to you, I don’t see patients who climb Flagstaff after, you know, having had what you’ve had, you know if they are on a beta blocker, and so you have to have that conversation and you are going to have to have a frank conversation with yourself about what it is that you want to accomplish and how long you want to be accomplishing it for. Yeah, look at Leonard’s in, right, same issue, he had to give up cycling, I don’t think most people have to give up cycling if they’re on a beta blocker. Yeah. But it’s an example of somebody who had to make a very, very difficult decision based on did he want to continue doing what he loved, and in doing so potentially end his life. I don’t think that’s what most people on beta blockers have to face. But it’s a very extreme example of what we’re talking about here. And I think if you’re on a beta blocker, and you’re finding Look, you can’t reach the maximum heart rate that you you need to or if you’re getting lightheaded when you try to go hard. Yeah, you need to have a frank conversation with your doctor and say, Look, is there an alternative that will confer the same benefits and confer the same risk reduction? And if there isn’t, then you need to think to yourself, have a conversation with your family? Okay, can I be happy doing things at a new level? Or do I need to stop and find something else? Or am I just going to take a risk and switch to a different medication class and understand that I’m going to be at a higher risk? Right?

Rob Pickels  36:28

Yeah, I think that Leonard ended up at a pretty reasonable alternative in that I think that his dysrhythmia was associated with crossing a particular kind of heart rate, where then he would have an increase in his dysrhythmia. He ended up riding in ebike a lot. And that made all the difference in the world, he’s still able to get out and enjoy, right? It’s

Jeff Sankoff  36:51

a great example of how you can modify if you have to be on one of these medications. Yeah, listen, at some point, we’re all going to have to make changes based on getting older and and, you know, we can’t do everything that we did when we were young. I mean, listen, my 14 year old does peed my pants off of me and almost everything. Yeah. And it’s great. It’s wonderful. But at the same time, it makes me realize that yeah, I’m gonna have to adapt a little bit and it’s okay. It’s okay. It’s like, adapting as you get older is just a fact of life. And then you know what, as long as we can find the enjoyment in those adaptations, I think it’s okay. Now,

Rob Pickels  37:30

let’s take a quick break from beta blockers to hear a funny story from Dr. Steven Siler, and also his views on balancing medication and the enjoyment of sports.

Dr. Stephen Seiler  37:41

One burning memory that is kind of funny, but it’s also a little bit strange is that I had a cycling colleague back in the day in Arkansas, and he was bipolar, and he was using lithium or lithium ish drug, you know, and when he would sweat, his sweat, ate up his bike. So So I, that’s the only example I have the direct effect of a medicated athlete that the medicine was destroying the bike, I don’t think it was doing him any harm, but it was destroying his bike. So that’s a humorous side of it. But as far as the the realities of taking high blood pressure medicine, maybe antidepressants, and so forth, you know, the high blood pressure medicine, obviously, will, beta blockers and so forth will impact physical performance. And that’s a tough reality for a lot of long term athletes where they’re used to having a certain capacity, but now they’ve developed arrhythmias or blood pressure, and they’re using these beta blockers and your identity, you know, as an athlete, I think is challenged because you have to decide between this evil which is the disease or the disease state and myself images has just taken a huge hit. And so I I think that’s an interesting psychological reality. I faced it a bit with atrial fibrillation to ever you faced it with afib. I never was medicated, but I was on in that period, when I was struggling a bit and having a lot of AFib episodes, I was really feeling like, wow, you know, my quality of life is just gone down the toilet, I’m never gonna be able to be an athlete. Again, I can’t do these tough workouts, you know. And fortunately, I was able to turn it around and it was a lot of stress in my life. But that’s what I see is that just our understanding of our bodies changes when we have to use medicines or we are given a diagnose.

Rob Pickels  39:39

You know, interestingly, with beta blockers and the research that I did, it doesn’t seem like there’s any deleterious effects on strength so strength training seems like it’s unaffected, maximal power. If you’re a track cyclist, maybe you’re just fine, you know, doing track sprints on a beta blocker, you know, in water. It’s not banned for any

Jeff Sankoff  39:58

interestingly enough, it is is banned for certain things. So for example, and this is obviously not going to be this audience, but biathlon, I was gonna say because yeah, cross country skiing a lot of those events where your heart rate is super high. Beta blockers are banned in those sports because they use them. So a great example of biathlon where they they’re skiing in this incredible effort. And then they have to get their heart rate under control so they can level the gun and shoot at those tiny little targets. Yeah, and beta blockers have been used by some athletes to be able to keep their heart rate under control.

Rob Pickels  40:31

Yeah, the list is like by athalon, archery, bowling darts, you know, things of that nature, right, because of that calming effect. And it’s actually it’s interesting recently, I’ve been seeing ads promoting beta blockers, to people who don’t have any hypertensive issues, but who have like a stage fright, and they have to be in front of large audiences.

Jeff Sankoff  40:54

Yeah. Because it keeps anxiety under control. It’s actually another indication for using beta blockers. Yeah. And again, the drug companies, right, they’re gonna have to pad their bottom line, but it is effective. But there are dangers. I mean, if you you know, we see patients who get syncope or fainting spells from being on beta blockers. So there are there are dangers.

Rob Pickels  41:18

Cool. What do you think? Should we jump away from the heart and jump over to a statin? Yeah,

Jeff Sankoff  41:21

absolutely. Statin is very much related to the heart. So yeah, I think so. Right?

Rob Pickels  41:26

Yeah. So, you know, satins, at least according to good RX are one of the number one prescribe medications in the world. And ultimately, it’s because they’re looking to reduce LDL cholesterol, low density lipoprotein, which is associated with things like heart disease and stroke. And there are people that we’ve had on the show before, you know, Dr. innego, sin, Milan, is a huge proponent against statins just mentioned that word around him and just watch, you know, watch his iron fly. I love the Basque passionate nature that he has. But you know, we commonly hear about things like like my algea, like muscle pain and muscle soreness associated with statins. So I’d love to start there.

Jeff Sankoff  42:07

Yeah, I didn’t know that Dr. Stein alone. Statin so it’s interesting. Let’s insert

Rob Pickels  42:12

a clip here.

Dr. Inigo San Millan  42:15

We don’t know why the mechanism so we know the status and the ad pants, if they’re like, high dose of statins or like lower potency of statins, they inhibit complex one in mitochondria. So you don’t want to inhibit complex one. We know that many, many studies down the road, they significantly increase the risks of diabetes, because there are more diabetes genic. Right, especially when it’s called the high the high intensity statins. And it probably could be because they inhibit mitochondrial function down the road. So it’s a little bit of a counterintuitive, or you know, desire to live longer, when you you might down the road inhibit your mitochondrial function, which is a key process of aging.

Jeff Sankoff  43:01

First, just to address that, listen, statins are widely prescribed for a good reason. I have nothing but the utmost respect for Dr. Sutherland, I actually am trying to get him for my own podcast, because I just reviewed his paper on the periodization of carbohydrates. I think he’s fascinating. And I really would love to chat with him. But with all due respect to him, he’s not a cardiologist, nor am I don’t play one on TV either. But I do think to Statins have a very, very important role for anybody who is at risk or has had a heart attack because they dramatically decrease the recurrence of heart attacks. And they dramatically decrease primary cardiac events in patients who are at risk. That being said, they do have important side effects, like we talked about before, every medication has risk benefit, and there is a pretty important risk profile for all statins. And it’s important, especially for this listening audience, which is an active listening audience. And we know that my apathy, which is what we’re talking about the muscle complaints that have been associated with statin use, they can vary from mostly benign, but they can be life threatening. And they happen in anywhere from 10 to 15% of patients, and they are important. And if you’re on a statin and you get them, then yeah, it’s going to be a big deal for you.

Rob Pickels  44:17

Right. And it seems like people are commonly reporting what this sort of muscle ache this muscle soreness, oftentimes it’s in their calves and their thighs is something that I came across.

Jeff Sankoff  44:27

Yep, that’s true that it tends to be thigh calf pain are the most common.

Rob Pickels  44:32

Yeah, certainly. Now it’s something and I don’t know if you can fill in this blank for me when I was researching this this episode, I did not necessarily see a clear reason we know that this is occurring in 10 to 15% of people. This is a real situation. I did not see an etiology to understand what is the actual mechanism that is causing these muscle pains.

Jeff Sankoff  44:57

It’s interesting. It’s happening at a very Low like biochemical like it’s really in the weeds, but basically what’s going on is statins decrease Coenzyme Q 10. And that seems to have an effect on mitochondrial function and muscle cells. And as a result of this, people who are on statins, not everybody, again, only 10, you know, one in 10, maybe 15%, will develop this kind of muscle pain. And in fact, there have been studies that have shown if you supplement with CO q 10, anywhere from 100 to 500 milligrams per day, that can actually help decrease the incidence of the symptoms now,

Rob Pickels  45:35

now, can I ask, and maybe this is just an opinion, right? And we’re on a podcast, this is not medical advice. I don’t think in people who are taking a statin but not necessarily feeling any of these symptoms, feeling the the myopathy of my algea, the muscle soreness is there potentially an effect that’s occurring that’s affecting their performance, or if you’re taking the statin and life is grand, keep on keeping on, it’s not doing anything negative to you? Yeah, I

Jeff Sankoff  46:03

haven’t seen anything that suggests that taking a statin decreases performance. But I don’t know that anybody’s really looked at that Statins have been looked at for a wide variety of things. Because the enzyme that statins inhibit, which is HMG, co A, which is neither here nor there. It’s an HMG co reductase inhibitor. That enzyme is found in a wide variety of different processes. And so Statins have been looked at in all kinds of things in treating sepsis and treating inflammatory process all kinds of things. And thus far, there’s been kind of plus minus in terms of how well it works. No question, big, big benefits for cardiac stuff. I haven’t seen anything that suggests that it improves or decreases actual endurance performance. But again, you know, there’s not too many young people taking this. And that’s generally where most endurance research is done.

Rob Pickels  47:00

Now, certainly, this is a decision that I’m going to have to be making pretty soon here, because of my chronic kidney disease, my nephrologist is concerned that my cholesterol is probably quite elevated because of all the protein that I’m leaking, and has requested that I get some some blood workup done. And we might have to make that decision of is a statin. right for me. And I know that, you know, as much as I have this, like little bit of a fear and anxiety around it, I think that the first step is, you know, if it’s indicated, then to give it a shot, and and see from there and then make kind of an individual decision, because we do have to be putting our health first. And even though we’re all athletes, sometimes we do need to consider sort of more of the long term wellness and longevity side of things as accused to the acute, you know, what am I gonna be able to do tomorrow? Yeah,

Jeff Sankoff  47:48

and again, I want to come back to those risk reductions, they’re very impressive, we’re talking a 25% decrease in the risk of myocardial infarction and death and people who have had a previous cardiac event and a 10% decrease in the chance of developing cardiovascular disease within 10 years for people who are at risk. So that’s pretty significant. And again, if you fall into one of those categories, then if you have a conversation with your physician, and you go over all of this, then I think he or she should be in a good position to guide you. And together, you should be able to come up with that. And those are real risks. I mean, we take a lot of medications for a lot less benefit than

Rob Pickels  48:31

right. Yeah. Now, so we’re talking about, you know, the opposite or the I shouldn’t say the opposite, but the risk is a muscle pain and some muscle soreness 10 to 15% of people. There is, as far as I know, a significantly more damaging situation that occurs less frequently. And that is an increased incidence of Rhabdo. My license, my license, my Lusas. No, it’s wrapped in my life. Okay, that’s what I thought. Yeah. And that’s like one in 100,000 cases, and I didn’t find any solid research that was really tying these together. But I did see a couple of case studies, you know, 50 year old marathoner presents with, you know, acute Rhabdo, and was taking a statin? Is this something that you’ve seen? Is it something that you can comment on,

Jeff Sankoff  49:15

the only thing I can say is that it seems to be associated with statin dose unless related to actual exercise. There you go. So again, those are case reports. And so you’re more likely to get robbed of my license, if you’re running an ultra or a marathon, and the fact that the person was on a statin, it’s not clear if the statin caused it, or if they’re just oh, you know, they’re so you know, coincidence. Yeah. But we do know that there have been cases where people who were not doing exercise developed a case of rhabdomyolysis, and they were on a high level of a statin. And if you looked at the cells, there was some, you know, biochemical issue that made it seem like the statin was involved, and it was a culprit. But there’s so rare, that it’s really hard to tie the two together. But it seems at this point that there’s been enough cases that The higher dosing of statins can be related with rhabdomyolysis,

Rob Pickels  50:03

there you go. I’d love to wrap this segment up with talking about maybe some alternatives that people can do if they’re concerned or if they are having some negative effects associated with statins. You know, I think that the common things that are talked about right to decrease your bad cholesterol, increase your exercise, hopefully, that’s not an issue with people that are listening to this, but it could be increasing things like fiber intake, decreasing your alcohol consumption. Interestingly, I saw an increase in whey protein supplementation was correlated with a decrease in LDL cholesterol. And then a couple other things you had mentioned, supplementing with coenzyme, q 10. Co, q 10. That seems like it might help alleviate some symptoms, and I also came across supplementing with vitamin D and carnitine, as well, may be beneficial. I think that it’s hard to say at this point, right? Because we don’t really understand that mechanism to well, maybe that’s a little bit of a shotgun method, just throwing some stuff, seeing what sticks, but maybe there’s some more science behind the CO q 10. There co

Jeff Sankoff  51:03

Q 10 is again, just related to the fact that when you take statins, you decrease the production of it. And so you’re supplementing and exogenous li as for everything else, I mean all the dietary stuff. Usually most people have tried to dietary stuff before they’re put on a statin and there is nothing as good as a statin nothing will reduce your numbers as fast or as dramatically as a statin. Well, that being said, combining all of those things will do even better. There you go.

Rob Pickels  51:33

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Rob Pickels  52:19

Well, Jeff, we just covered a couple medications that people are on probably long term multiple months to multiple years. Let’s cover something that is maybe a bit more of a short term. There’s some considerations when athletes are taking antibiotics.

Jeff Sankoff  52:34

Yeah, antibiotics are another one of the big boondoggles for drug companies and they are a very widely prescribed medication that unfortunately, probably doesn’t need to be taken as often as it does. We take antibiotics for a wide variety of reasons. But the vast majority of them in adults tend to be for respiratory infections that don’t require them. Sure. When we get a respiratory infection 90% Plus or viral, which don’t respond to antibiotics. So infections when we think about an infection, an infection is caused by a virus it’s caused by bacteria. It’s caused by a fungus one of those three things. Viral infections comprise the vast majority of infections. Bacterial infections are the only things that respond to antibiotics. Fungal infections are exceedingly rare. If you do get a fungal infection, it’s usually because you have a depressed immune system or some other special circumstance. Fungal infections are generally more chronic and indolent. But need special antifungal medication. Sure, what’s the issue with taking antibiotics if you don’t need them? First, let’s just talk about our sort of societal kind of pressures that lead to antibiotics being taken as much as they are, none of us want to be sick. And we kind of all grow up in an environment where when we’re sick, we go to the doctor. And we have this expectation that we’re going to leave with a piece of paper that at least if you’re my age, left with a prescription that you went to the pharmacy and you got a pill bottle and you took something cherry or banana flavored and you got better in a few days. We’ve learned over time that taking antibiotics when you don’t need to take antibiotics leads to again, this whole risk benefit balancing act, there are risks associated with antibiotics. Number one, we predispose ourselves to infection by bacteria that are resistant to those antibiotics. Number two, we teach bacteria to be resistant to antibiotics. And number three, we cause problems within our own bodies. Because we are administering antibiotics to our organism that is populated by a wide variety of bacteria on a normal basis, that little ecology within ourselves called the microbiome, which we wipe out when we give them antibiotics and we then leave ourselves prone to all kinds of problems

Rob Pickels  54:55

and I will say this is one of the most mind blowing concepts about the human body To me is the variety of the microbiome, but also the importance of the microbiome to functions throughout our entire body. Right? Okay, I can understand that we have some bacteria in our gut and that they help us digest and absorb food. It’s a pretty direct link, I get that. It’s amazing to me, though, that there is a link between our brain our mood and our gut microbiome and the interconnectedness of all of that we really are talking about a holistic systemic conversation here.

Jeff Sankoff  55:33

Yeah. And what’s been really, really interesting to me has been recent studies that have shown how the microbiome impacts performance, that when you wipe out the microbiome, endurance performance is dramatically affected, like just mind blowing stuff. And that’s why I mean, I have always been on event where don’t take antibiotics if you don’t need them. It’s, it’s bad for us societally. It’s bad for us, just in general. And now I’m realizing it’s bad for us individually as athletes, you don’t want to take antibiotics unless you really need them. Now, there is no question if you have a bacterial infection, then yes, you should be. And I am not the one to tell you not to take Yes. But your doctor is the one to tell you not just right. The vast majority of people who get prescribed antibiotics almost never need them. I constantly hear people telling me they have sinusitis, sinusitis is viral 99% of the time, I constantly hear people telling me they have bronchitis bronchitis is viral 100% of the time. And yet, a lot of doctors will prescribe antibiotics because the Patients will demand it or because the patients believe they needed to and sometimes the doctors just don’t want to be bothered with spending the time to explain or listen, we work in a in an environment where healthcare is a business and patients are the customers and the customer is always right. And so it’s a it’s an unfortunate setup. I am pleading with you the listeners, please. If you think you need antibiotics, go in with an open mind and don’t demand them. And instead, tell your doctor, look if I don’t need antibiotics. I don’t want them because you as a patient will be better off not getting antibiotics if you don’t need them, right. Because of these impacts on the microbiome.

Rob Pickels  57:14

The advice isn’t if you’re sick, just suffer through it, you’re going to get better. That’s not the advice given the advice is still hey, if things are wrong, go talk to your doctor. But don’t think that this is a magic bullet.

Jeff Sankoff  57:26

Exactly, exactly. Now, the impact on the microbiome when you take antibiotics, antibiotics are indiscriminant. If you have a bacterial infection, antibiotics will take care of those bacteria. But the antibiotics don’t really care which bacteria are causing your infection are going to take out everything. And our gut is populated with bacteria that help us like you said with digestion. And it turns out a lot of that digestion is so when we exercise and we’re taking all these long chain, poly Marek carbohydrates, a lot of that is just basically another word for that is fiber. Now we don’t digest fiber, but those bacteria do. And as bacteria chop up those little fiber into little much more manageable short chain carbohydrates that we then digest and then absorb and then use for energy. Well, when we wipe out our microbiome, we turns out, we don’t do that so well. And we don’t perform very well. But there’s more to it than not, because it also turns out that those microbiota appear to have an impact on how our muscles work. It’s not clear exactly how but they’re tied together somehow, just like you said before the brain and mood and everything else. I mean, there’s there’s all these ties, and they have done experiments where they fed groups of mice. I love this experiment, because they had these three groups of mice, and they had them running like doing these training sessions on these little mouse sized treadmills. And they would feed them the same diets. And then one group would get antibiotics and the other group wouldn’t. And it turned out that in a test to exhaustion, the ones who got antibiotics performed terribly, and the ones who didn’t did great. And then if you took gut bacteria from the healthy mice and transplanted them into the mice who had received antibiotics and did nothing else, they performed the same as the other ones. And so it was it was not that the antibiotics made them worse. It was just the loss of their microbiota, and transplanting microbiota, not doing any extra training, made them perform the same. That’s incredible. So it just to me highlights not only the importance of our microbiota and how much we have to protect it, but it also tells me how careful we have to be about taking antibiotics only when we absolutely need them as athletes there you go. And if we do need them, if we do have to take them there are some things that we can do to try and replenish our microbiome as fast as possible. There are various probiotic foods, foods that are fermented, like pickles can Bucha kimchi, all those foods do a good job. Foods that have active culture like yogurt, cottage cheese, those are really good at helping to replenish and you can buy you can actually buy these little capsules of La lactobacillus, which is a big part of our microbiome. So if you have to take antibiotics after you finished antibiotics, you can eat those foods, take those capsules, and you can help to speed up the pace at which your microbiome gets replenished.

Rob Pickels  1:00:15

Is the after you finished is that kind of an operative in this situation? Are you undoing you know, like, if you’re eating the yogurt, while taking the antibiotic is the yogurt not necessarily beneficial until after you finished your course of antibiotics,

Jeff Sankoff  1:00:29

there’s actually so one of the side effects with antibiotics is very commonly diarrhea. And it turns out that eating yogurt while taking antibiotics can actually prevent diarrhea in a lot of patients. So there’s no harm in taking these things at the same time. But the longer term benefits will be after you finish the antibiotics because anything you take while on antibiotics is going to get wiped out perfect. Before

Rob Pickels  1:00:53

we learn more about fluoroquinolones, let’s hear from athlete Jack Burke about his experience with antibiotics and Achilles tendon injury.


I don’t take anything for medication at all, because I’ve just always found it just tends to set me back more than is. But like one of the nice assets that I have going for me is I’ve only been sick once in the last 12 years. Like I never get sick ever. When guys talk about like, you’re gonna get sick if you over train and stuff like this. Like I always just like, that’s not gonna happen, where like somebody has like the sniffles, and they don’t want to be around me, I’m like, you can give me a kiss. I’m not gonna get sick. Like, it’s not gonna happen. I’m fine. But I think that’s because I don’t know, maybe that’s genetic, whatever I was really obsessed with, like the cold water thing. So that’s the thing that I tell myself why it helps. I found like horror stories from medication. I do remember the one time I did get sick, was 2017 to two boasts. And the doctors gave me this medication. And this was an example of it really screwing with me. They gave me some medication. And I want to say it was like Avelox or something like that for a chest infection. And it got rid of that. But there was a side effect of it where like tendon rupture. And my Achilles tendon almost snapped in the race. Like I started get this really weird feeling where it was like my Achilles tendon and felt like crunchy. And I was like, What is going on? This is the weirdest thing. And then I did you know, the WebMD thing where you really scare yourself like to self doctor, all the stuff in the hotel it to two boats. And I’m like, Oh, my goodness, my Achilles tendon is almost gonna run. And so I stopped taking it. Right there are like years later, I was at a crash in race here in the Czech Republic. And they thought I cracked my eye socket. And so my eye was all swollen up. And they gave me ibuprofen for that. And it was the first time I’ve had ibuprofen in years. And it gave me such problems with my stomach that I just had like all stomach problems the next day, so I was having more problems from this like pain medication than from the injury itself. And so I’ve always I really went down like Swain. Tufte. Again, that was my mentor. And he taught me all about like the circadian rhythms, sleep, sunlight, grounding, all this woowoo hippie stuff that I thought was just funny at first, but I’m telling you, it works. Like I never take medicine. I never get sick. All I do is all this goofy stuff where my teammates make fun of me, but that’s my opinion on it.

Rob Pickels  1:03:00

Jeff, that was an awesome discussion about kind of the broad spectrum. See what I did there of the antibiotics like that. I’d love though to touch on one in particular because this is let’s be honest, this whole episode is about me. This is something that has affected me in the past. And that is a specific class of antibiotic called fluoro quinolone. Like what Cipro Levaquin are two different types there can lead to things like tendinitis, and maybe even ligament and tendon rupture.

Jeff Sankoff  1:03:30

Yeah, not ligament rupture, but tendon rupture. Achilles tendon rupture is the one that’s been associated with ciprofloxacin, particularly not so much for some reason with Levaquin, although there is a theoretical risk and it’s not completely well understood. Yeah. The association though, is so great that Cipro now comes with a blackbox warning. And blackbox warning just means that the FDA issued this warning to prescribers and basically says, You got to be aware of this, be careful prescribing this only prescribe it to people if it’s really important and necessary. The fluoroquinolones came out when I was in medical school, it was revolutionary at the time, because it was the first new class of antibiotics in quite some time. And they provided us with a new way of treating gram negative bacteria, which are particularly difficult bacteria to kill. And they were great, but we started to see these tendinopathies and tendon ruptures, specifically the Achilles tendon, and there were a couple of high profile athletes who had dumb and they were obviously devastating to them. And it turns out that the Achilles tendon is most likely tendon to rupture. And not everybody who has a tendon rupture has been on a fluoroquinolones and not everybody on the fluoroquinolones is going to have a tendon rupture. However, if you’re on a fluoroquinolones, the likelihood of having an Achilles tendon rupture is significantly higher. fluoroquinolones are associated with a almost four times greater risk of a development of Achilles tendonitis or rupture. So that’s pretty significant. Now again Achilles tendonitis isn’t that common, but four times more common is four times more common. Yeah. And again, not totally understood why the antibiotic seems to have this predilection for tendons, but it is what it is. There are certain things that make you more likely to get this problem if you’re on a fluoroquinolones, these are higher age. So age greater than 60. People who’ve previously been on steroids, people who have renal issues, you mentioned you’ve had renal issues, people who have diabetes and people who have a history of other musculoskeletal disorders. So any or more of those predisposing factors will increase your risk for fluoroquinolones induced tendon disorders, but you don’t have to have any to still have these problems.

Rob Pickels  1:05:46

Yeah, you know, for me, it was I don’t remember exactly which medication I was taking. But I ended up with like a bilateral Patellar tendinitis from the skiing, like my knees never hurt from skiing, what is going on and started looking into this? And yeah, lo and behold, it seems like it might have been associated with the antibiotic that I was taking. And because of that, when a friend and a training partner had kind of like a similar complaint a few years later, I was like, Are you taking blah, blah, blah, by any chance? And he was like, actually, I am. And I was like, there it is the smoking gun. But you know, with us as endurance athletes, I think that we need to understand, hey, you’re out, you’re running a marathon, you’re doing a trail run, you’re crashing your mountain bike, these are all things that are putting additional stress onto these components of our body. And you know, it’s maybe worthwhile looking for alternatives, perhaps in this because I don’t know, I mean, some of these things, Achilles tendon rupture. I mean, this is a pretty significant, you know, damage, a pretty significant recovery, surgery, to repair, so on and so forth.

Jeff Sankoff  1:06:48

Yeah, you mentioned earlier about doing your own research. And I’m always a little cautious of the idea that going on the internet is going to somehow make your understanding of something more than the people who’ve really done the research is a little, I worry about that. But that’s not to say that you shouldn’t look and you shouldn’t ask questions you should just always do so understanding that you may not have the whole picture. And I say that, because I watch these drug advertisements on television, and they list the side effects. And I mean, they have to list everything they do. And they’re usually opposite each other. Right? And it’s like, you know, some of the side effects are waking up in the morning, you know, it’s like, what are you supposed to do with with these things? So I think you just have to be, you know, yes, you want to be an informed patient. And you want to know what the potential risks are whenever you take a medication, but just recognize that they have to list everything and it doesn’t mean that just because, you know, a tendinitis for example is listed, it doesn’t mean that that’s a gonna happen to you or be that common. Now with fluoroquinolones, it’s obviously common enough that the drugs have been restricted in terms of how they’re used. But in any medication you take, there’s going to be a host of side effects. And it doesn’t mean you shouldn’t take it, it just means you should probably have a conversation with your physician or your pharmacist to get a sense of how common those side effects are and what you should be looking for now.

Rob Pickels  1:08:08

And certainly when looking in the literature, it is definitely mixed in terms of the incidence rates and particular drugs. And there is a lot of nuance in this conversation. For sure. I don’t think that there’s a good blanket statement recommendation that could be given. Absolutely. So I want to shift gears a little bit. And that is good. Recycling is good. And I shift electronic gears oftentimes, too, which is nice. I want to move over to a topic that isn’t talked about much, if anything, I almost think it’s a little bit of a taboo topic. And that is around ADHD medications and the stimulants associated with treating that this is something that seems like is increasingly common for people to be taking to be prescribed. I know that there are some people in the industry who have mentioned quite openly and I applaud them, Nate, the founder of trainer Road, talks about his ADHD med use, I think that he’s on Adderall, I could be wrong, and how that was ultimately relatively revolutionary in his life. And I think that other athletes may be taking ADHD, whether that’s Dex methylphenidate, or Adderall or whatever, at increasing rates. And so I’d love to talk about the considerations when taking stimulants during endurance exercise. Sure,

Jeff Sankoff  1:09:20

I think there’s a couple of things that you need to think about with these medications. One is their effect on appetite, which for us as endurance athletes who are expending a lot of energy, we have to be fueled. And if we’re not adequately fueled, then the ability to perform is severely impacted. And we know that these medications are associated with severe restriction of appetite and many who take them and that is a potential pitfall. So something to be concerned about. And then the second thing is just their impact on cardiac activity. They’re all stimulants. Therefore, they all have some degree of have effect on heart rate. And they can increase heart rate during exercise that can increase resting heart rate. And it’s just something to be cognizant of Now,

Rob Pickels  1:10:07

certainly, you know, I was diagnosed with ADHD a few years ago, I take Dux, methylphenidate at times, I do not take it regularly, mostly because I don’t necessarily like how it makes me feel, and it affects my sleep and things like that. And I haven’t really cared enough to look for alternatives with my doctor. But some things that I have noticed and I’ll say maybe this is anecdotal, when I was taking medication more regularly, things like my heart rate variability was significantly lower than it was when I don’t take the medication, right. And so I know that there are a lot of people that are using things like whoop, to varying degrees of success, right with things like heart rate variability, but we can have really profound effects there. The other thing that was really interesting to me, I did a study with Dr. Sam Milan on some I think I can talk about this now, or maybe breaking an embargo at this point on a continuous lactate device where I had to wear a continuous lactate monitor 24/7 for a couple of weeks at a time I actually worked for over them during the test. But I also had to do serial fingerprick lactate sticks on myself, essentially like every hour of my waking day. And it was incredible to see how much higher my resting lactate concentrations were based on taking the stimulant Dex methylphenidate, which was really profound to me. And even things like caffeine and coffee actually drove my lactate up higher. And I have noticed anecdotally through the years when I when I have taken stimulants like this, it very much affects any lactate testing that I’m doing my results are profoundly different than when I haven’t had coffee to drink or taking a medication like this. So ultimately, I just want to inform people that you know, if you are doing testing like this, you know, or if you are looking at things like heart rate variability, using heart rate zones, all of that might be affected by some of the stimulant use that people are using to treat things like ADHD.

Jeff Sankoff  1:12:06

I think that’s really interesting about the lactate. I’ve not heard that before. And I can’t think of a biochemical reason for it. But it’s really interesting that that’s happened. And I wonder if that is something that other people have noted as well. Yeah, the heart rate stuff is 100%. And so is the sleep. I should have mentioned that I forgot about that in terms of the side effects, but the heart is stuff that 100% We know that a lot of different medications, beta blockers we talked about earlier, definitely impact heart rate variability. And I’m not a huge subscriber to heart rate variability. I think heart rate variability is a little bit over called in terms of its utility as a primary determinant of fitness or readiness, things like that. I think it’s a it’s something that we can use as a metric. But I think people may be overcall it in terms of its prime importance. That being said, almost any medication is going to have some kind of impact on heart rate variability, especially if it touches the nervous system or touches the cardiovascular system. And what its importance is is unclear, we don’t understand Yeah, I don’t really know. And I think that’s the problem with heart rate variability, I think people have gotten ahead of the you know, they’ve put the cart ahead of the horse a little bit with heart rate variability, they kind of are like, heart rate variability is based on chaos math, which means that tiny little perturbations can have big downstream effects. People are using heart rate variability very linearly, which is exactly the opposite of what it’s supposed to be. So I don’t know what decreases in heart rate variability related to a medication should be interpreted as exactly what they’re there. Yeah. And I think that if the medication is working, and you’re able to perform despite those changes in array variability, then I think that’s what’s important. And then you just have to use that change in heart rate variability as your new baseline. But as you said, I think it’s just important that you know, and that you recognize that that’s an impact or an effect of the medication. Again, back to that risk benefit balance that we talked about earlier.

Rob Pickels  1:14:08

Yeah, certainly, to bring up the water side of this, it seems like a lot of these medications associated with ADHD treatment are not prohibited outside of competition, and they are prohibited during competition. And as far as I know, unlike diuretics, it is very difficult to get a t e for something like Adderall.

Jeff Sankoff  1:14:28

I don’t know about Adderall. So there is another one that is called the trade name I’m sorry, I hate using trade names. I prefer to use just generics. But Modafinil is another line that is used by shift workers like myself okay. So it is often used by emergency physicians or nurses or people who have to do night shifts on a changing schedule and we’ll use it to help us get through the night shift. And I called water about it because it is listed on their banned in competition list and I called them up and asked them about it to up and they said we know shiftworkers use This medication, it is banned and competition. We know it has a very long half life. If you ever tested positive, you would just come and talk to us explain what your job is. And it would, it would not be an issue. And I kept that conversation. It’s in my it’s in my, you know, to keep a folder of my emails. Yeah,

Rob Pickels  1:15:20

yeah, I swear I’m a doctor. I’m not just a podcaster. Changing gears, our attention span for ADHD drugs. You know, I brought that up, because it seems like the the prescription of that is increasingly common. And I think that the same can be said for the last class of medications to talk about today. And that’s anticoagulants. You know, as you mentioned, off air. We are seeing increases in atrial fibrillation may be associated with athletes and because of that an increase in the prescription of anticoagulants as well. Yeah,

Jeff Sankoff  1:15:54

as we get older as we’re on the bike for more and more years, we’re prone to what’s called ventricular enlargement or ventricular hypertrophy. And that’s normal. It’s not dangerous necessarily, but it makes us prone to a arrhythmias or dysrhythmias. And the most common one is atrial fibrillation. Atrial Fibrillation in and of itself is not necessarily dangerous. But the problem is, is if the atria don’t beat in a coordinated fashion, they come to a sort of a standstill, and the blood that pulls within the atria can clot. And if one of those clots suddenly becomes dislodged, it shoots off to the brain and causes a stroke, and atrial fibrillation remains a very high risk factor for strokes. And the way to treat that is to put people on an anticoagulant so that they don’t form clots, and the use of anticoagulants has been a boon to decreasing stroke occurrence and patients who are at risk or who have atrial fibrillation, there are risk scores that exist in order to determine their likelihood of stroke in patients who have atrial fibrillation, and you don’t have to score very high on that risk score in order to be recommended to be an anticoagulant. And what that has resulted in is a lot of people in their 50s and 60s who continue to be very active, including on bicycles, who are taking these medications. And where it used to be the medication that was taken was warfarin, or Coumadin, which was a medication that was easily reversed. We now see people taking medications like river rocks a ban or all these other newfangled and they’re called noacs, novel oral anticoagulants,

Rob Pickels  1:17:35

right? And so like what Lovenox is a brand name. And Lovenox

Jeff Sankoff  1:17:37

is is a low molecular weight, heparin

Rob Pickels  1:17:41

injected take it out this way, I’m not the doctor.

Jeff Sankoff  1:17:45

There are all kinds of different anticoagulants, but the the noacs are these novel oral anticoagulants, which have revolutionized the use of anticoagulants. So it used to be everybody was taking warfarin or Coumadin. And what would happen is that once or twice a week, they would have to get their blood checked to make sure that they were taking the medication in the right dosage and that they were anticoagulated to the right amount. With the no X, there’s no need for monitoring you. We know based on your renal function and the dose of medication you’re taking that you are precisely anticoagulated, the medications were great. The only problem is, is that if you bonk your head, I can’t effectively reverse those medications with Coumadin, I could I could give you an antidote, and that would stop your bleeding. With a no AK. We don’t really have effective antidotes. If you start bleeding, you have a big problem. And cyclists are unfortunately especially if you’re racing things like crypts, you have a common habit of falling down and hitting your head. And even wearing a helmet, it’s not going to stop you from having a serious bleed.

Rob Pickels  1:18:45

And so we’re not talking about the downside of scraping your elbow and continuing to bleed as you finish your bike ride, we’re talking about something a bit more serious,

Jeff Sankoff  1:18:54

much more serious than that. Now, that’s not to say that cyclists on noacs Shouldn’t be participating in cycling events. It’s only to say, if you’re on one of these you have to be very aware and the people around you have to be very aware because if you fall in hit your head and lose consciousness. People have to know immediately that that is a high risk and you have to be transported to emergency and somebody there has to know that you’re on one of those medications. That’s really all we’re saying.

Rob Pickels  1:19:19

So how can somebody make sure that that information is easily known, especially in a situation where they lose consciousness?

Jeff Sankoff  1:19:26

I am not sponsored by nor am I promoting any particular product, but I have on my watch on my Garmin I have one of those Road ID okay. Yeah, a little piece there it is that talks about, you know, who should be called in a emergency and what medications I’m on. So that’s one example. As long as you have that information, as long as somebody knows that information, as long as it’s very easily ascertained that you’re on those medications. Honestly, if you’re on a noec or crit is probably not the kind of event you should be participating in her. But listen, if you’re on a note you could be descending and your tires could slip out on some gravel. So I mean, you could still have problems, crashes happen, I really can all attest to that risk benefit. That’s what we’re talking about here. But I think the point of discussing no axe is not whether or not you should be taking them. That’s a conversation that you’re going to have with your physician. And you’re going to make it very clear. Look, I’m a cyclist, I’m not going to stop right now. But your doctor needs to know that you’re a cyclist to in order to make a decision about which medication is best, because of the noacs, there are a couple of them that we can reverse more efficiently than others. And if you are doing crits, maybe you need to adapt as we said earlier, or maybe the risk of being on medication is higher than the risk of stroke. And maybe you’re not going to be on the noec during the time that you’re racing.

Rob Pickels  1:20:46

Now, I think that you mentioned something that I just want to repeat. And that is having the conversation with your doctor, I think that that sentiment has come up multiple times throughout this, and I just really want to highlight it because it’s very much a patient doctor relationship. And you need to be able to have an honest and frank conversation with your doctor so that they are well informed. Because all of this is part of the decision making process. And your doctor ought to take all of this information into account when thinking about the best therapeutic course moving forward. And, you know, if you’re not forthright with this really important information, then then the doctor is going to make the best decision they can on incomplete knowledge. And so it can be hard and I understand it right? It’s probably really easy for an ER room physician to say, Hey, man, just talk to me about it. You know, I think that a lot of people kind of view doctors as sort of this. I don’t know how to really describe it, you know, but like doctor knows best, right? And I’m just going to do whatever the doctor says. But that doctor, you know, they’re on your side, and they want to do as best by you as well. And so yeah, make sure you’re having those conversations and ask questions.

Jeff Sankoff  1:21:54

And you know, we’re all busy. And we often have a lot of pressures on us to see more patients or to do certain things in a certain timeframe. But don’t be shy to get your money’s worth, and make sure that you get all of your questions answered. And if your doctor says, look, they don’t have time or whatever, then say, well, how can I ask you questions because many doctors these days will have a means to for you to contact them electronically and ask your questions that way. So don’t be shy. You’re the patient, you’re the customer. And you should feel satisfied that you got all of your questions answered in a way that works for you. Awesome.

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Rob Pickels  1:23:17

Before we sign off, Taylor Warren has some sage advice for evaluating the need for medication but as always, please discuss with your doctor.

Jack Warren  1:23:26

I’ve never taken medication and even like yeah, common painkillers, Advil, Tylenol, it’s like, I’ll take those very, very sparingly. There’s a saying I really enjoy and there’s no solutions only trade off. And that quote comes to mind when I think about medication, where a lot of times medicine or medication, especially in our modern day is it’s really a band aid the to cover up a symptom. So you’re not actually taking care of the underlying issue. You’re just putting a bandaid on that a symptom of that issue. And I think that is a mistake in most cases, because you’re you’re basically blocking signals that your body is trying to tell you right your body, if you have a headache, your body’s trying to tell you something, it’s not an excuse to take a painkiller to make the headache go away. It’s an opportunity to learn why your body’s giving you the signal and to learn more about your body. Maybe you’re dehydrated, maybe it’s something really common and easy to fix. That’s kind of my opinion on medication. I think, you know, medication is necessary at some point maybe as more like a last resort type application. But I think in general people are over prescribed and they’re not actually doing their body you know any good taking medication.

Rob Pickels  1:24:38

Well, Jeff, absolutely incredible episode today. If anyone enjoyed Hopefully everyone enjoyed this episode, but check out Jeff’s podcast right what’s the name of it?

Jeff Sankoff  1:24:47

It is called the try doc podcast. It can be found on all the usual platforms.

Rob Pickels  1:24:52

Love it. Awesome. Well, once again, thank you appreciate it.

Jeff Sankoff  1:24:55

Absolutely enjoyed being here.

Rob Pickels  1:24:56

That was another episode of Fast Talk the thoughts in opinions expressed on Fast Talk are those of the individual. Subscribe to Fast Talk wherever you prefer to find your favorite podcasts. Be sure to leave us a rating and a review. As always, we love your feedback. Tweet at us at Fast Talk Labs or join the conversation at forums dot fast talk labs.com to learn from our experts at fasttalklabs.com. For Jeff Sankoff, Brady Homer, Dr. Stephen Seiler, Jack Burke. and Taylor Warren, I’m Rob Pickels. Thanks for listening!