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June 21, 2007

BehindTheMedspeak: Can Bengay kill you?

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Up until eleven days ago I would have said, "Of course not."

I mean, I make a living in a specialty that a former chairman of mine called "controlled poisoning," so you'd think I'd at least have heard of the possibility.

Not so.

On Sunday, June 10, 2007, I read in the New York Times a story that taught me something I didn't know.

Here's the article.

    Muscle-Pain Reliever Is Blamed for Staten Island Runner’s Death

    The sudden death of a 17-year-old Staten Island high school track star was caused by the accidental overuse of an over-the-counter remedy routinely used by millions of Americans to treat sore muscles and joints, the New York City medical examiner ruled after a two-month investigation.

    The athlete, Arielle Newman [above], a cross-country runner at Notre Dame Academy on Staten Island, died after her body absorbed high levels of methyl salicylate, an anti-inflammatory found in sports creams like Bengay and IcyHot, the medical examiner said Friday.

    The medical examiner’s spokeswoman, Ellen Borakove, said the teenager used “topical medication to excess.”

    She said it was the first time that the office had reported a death from use of a sports cream.

    Ms. Newman, who garnered numerous track awards, died on April 3.

    Methyl salicylate poisoning is unusual, and deaths from high levels of the chemical are rare.

    “Chronic use is more dangerous than one-time use,” Edward Arsura, chairman of medicine at Richmond University Medical Center, told The Staten Island Advance on Friday. “Exercise and heat can accentuate absorption.”

    Dr. Ronald Grelsamer, of Mount Sinai Medical Center, said Ms. Newman had a very abnormal amount of methyl salicylate in her body.

    “She either lathered herself with it, or used way too much, or she used a normal amount and an abnormal percentage was absorbed into her body,” he said.

    Ms. Newman’s mother, Alice Newman, said she still could not believe that her daughter’s death had been caused by a sports cream.

    “I am scrupulous about my children’s health,” she told The Advance. “I did not think an over-the-counter product could be unsafe.”

    Johnson & Johnson, the makers of Bengay, expressed sympathy for the family in a statement.

    The company reminded consumers about “the importance of reading the label on this and all over-the-counter medicines to ensure safe and proper use.”

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    The label on Ultra Strength Bengay states that consumers should apply the product no more than three or four times daily and should stop use and see a doctor if the condition worsens or symptoms persist for more than a week, said Meghan Marschall, a Johnson & Johnson spokeswoman.

....................

Then last Thursday, June 14, Steve Yanda of the Washington Post wrote about the untimely death.

Here's his article.

    Are Muscle Creams Worth It?

    Death of N.Y. Athlete Puts Spotlight on Products That Trainers Shun

    Mike Spooner smelled the distinctive aroma of muscle creams such as Bengay and IcyHot whenever he set foot on a track. The scent, he said, was nearly everywhere — and even more noticeable at indoor track and field meets — as the products were used by nearly every competitor, including himself.

    Spooner, an All-Met distance runner who recently completed his senior season at West Springfield High, is one of several Washington area track and field athletes who say using the wintergreen-scented liniments to treat muscle soreness is prevalent among their peers, despite the fact that team trainers do not recommend the products. Now, muscle creams have drawn attention because toxicology tests revealed last week that the April death of a 17-year-old in New York was caused by overusing such rubs.

    "Anyone educated [in athletic training] in the last 25 years doesn't advise kids to use that stuff," said Jon Almquist, athletic training specialist for Fairfax County Public Schools. "The demand is due to marketing. That's the only reason why [athletic] trainers even have it."

    Arielle Newman [below],

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    who ran for Notre Dame Academy in Staten Island, was found dead at her home on April 3. Toxicology tests showed that her blood contained lethal amounts of methyl salicylate, an active ingredient commonly found in products such as Bengay and Icy Hot. The New York medical examiner's office reported Newman had used "topical medication to an excess," causing salicylate poisoning over time.

    Alice Newman, Arielle's mother, said her daughter used different muscle creams — often borrowed from teammates — in between races at track meets. The coaches and athletic trainers on Arielle's team did not advise her daughter to use muscle creams, Alice Newman said.

    "I asked her if she used [muscle creams] at practice, and she said no, because they don't run as fast at practice," Alice Newman said in a telephone interview. "I didn't smell it in the house. I didn't smell it on her clothes."

    Despite the medical examiner's report, Alice Newman said that her daughter "wasn't using any more than the recommended" dosage.

    Physicians contacted for this article said they had not heard of any other cases of salicylate poisonings connected with muscle creams.

    Bengay

    In January, Newman's high school coach told her mother that she was not recovering from races as quickly as she had before. Shortly thereafter, Alice Newman took her daughter to the doctor, and she was prescribed two inhalers used to treat asthma patients. The inhalers did not improve Arielle's condition, Alice Newman said, and the doctors could not pinpoint any other medical problems. Medical examiners said the prescribed medications did not contribute to Arielle's death, Alice Newman said.

    West Springfield's Spooner said he used muscle creams rarely, only to help soothe a tweak in his legs that was going to be a constant annoyance.

    "I used it to keep my mind off that and on the race itself," Spooner said. "It may be more of a mental thing. It's not advised, and it probably only half works."

    Tynita Butts, a rising junior track athlete at T.C. Williams, said she uses Bengay occasionally to treat muscle cramps. "We don't use it on a daily basis, just if our muscles are really tight. We do our warmups with all our [warmup] clothes on. It does the same thing."

    The marketing appeal of muscle creams is one of the few reasons the products still are popular today, Almquist said. He said they provide little more than a placebo effect for their users.

    "The chemical [in the rubs] is just an irritant to get the skin warm," Almquist said. "It doesn't do a whole lot physiologically. Physical rubbing [a muscle] is going to cause the most change."

    Adults and people with darker skin complexion are at less risk, said Bernard Griesemer, a member of the American Academy of Pediatrics Council on Sports Medicine and Fitness. He said young people with sensitive skin who apply a lot of muscle cream in one application (or lesser amounts in more frequent applications) are more likely to incur problems. Newman was white.

    "If you add anything to the equation, such as dehydration, high sweat rate or a fair complexion, you can get into trouble," Griesemer said.

    Since young athletes are prone to both dehydration and high sweat rates, the vulnerability to salicylate poisoning will always be present if muscle creams are in use, he said.

    "It's not as much of a sports issue as it is a lack of knowledge by the public on how to evaluate and how to use over-the-counter drugs and medication," said Sam Seemes, the chief executive of the U.S. Track & Field Coaches Association. "The manufacturer doesn't know the complete circumstances in which the product is being used. We, as a public, tend to push those limits."

    Johnson & Johnson, which makes Bengay, released the following statement after Newman's death: "We feel it is important to remind consumers of the importance of reading the label on this and all over-the-counter medicines to ensure safe and proper use."

    Alice Newman believes the labeling and directions on muscle creams need to be changed. Newman said she would like muscle creams to become prescribed medications.

    Seemes, meantime, said he doubts that Newman's death will cause much change in the way muscle creams are used.

    "If there is a car crash, people will slow down to look," Seemes said. "But if the traffic is clear up ahead, then they'll probably speed on up to whatever they were going before."

....................

When I initially saw the June 10 Times article my first thought upon viewing the headline — "Muscle-Pain Reliever Is Blamed for Staten Island Runner’s Death" — was that the athlete had taken an oral overdose of some anti-inflammatory drug like Motrin or Advil.

I was as surprised as you or any of the physicians contacted by the Post reporter that something like Bengay applied topically can kill.

So rare is severe toxicity that when it happens, it's reportable: witness this 2002 paper describing a single case, published in Emergency Medicine Australasia.

I just happened on the following warning, possibly based in part on the 2002 case reported above, posted on January 15, 2003:

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Let's hope word gets out before another catastrophe happens.

June 21, 2007 at 01:01 PM | Permalink


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Comments

you know if you read what they say it says dont use with a heating pad and useing before you run is kind of stupid yes im sorry that people die from it but iti s using your brain . your wondering why I am talking o have study bengay and every thing in it

Posted by: Paul | Oct 19, 2008 11:19:16 PM

Two thoughts.
Athletic types may be more at risk from this because their skin is more likely to be flushed during exercise than the more flaccid members of the population, who rarely break sweat. This would facilitate absorbtion.

Do these creams actually do anything anyway? I always assumed they just hurt a lot to gate the pain from something else.

Posted by: | Jun 22, 2007 2:42:32 PM

Interestingly, Warfarin is also used to poison rats.

Posted by: ifimust | Jun 21, 2007 4:26:24 PM

i'm wondering if her physiology had something to do with it. in order for poisoning from a topical cream to occur she must have had to use massive amounts over a long period of time. i'm assuming in most cases the "active ingredient" in the cream never makes it past the dermis. also, i figured it was the menthol or camphor in those creams that gave a sensation of "the cream is doing something" when it is just a sensation. in the meantime i'll stick to salonpas, thank you.

Posted by: Jane | Jun 21, 2007 3:41:19 PM

I heard about this on NPR a couple of days ago when I was out walking and it made me wonder... If salicylates were the problem, what about various acne medications that contain salicylic acid? Most people would use them only on the face, obviously, but if someone had a raging case of acne on his chest and back, too, and, not wanting to be the Zit King at the beach, decided to treat those areas vigorously, on a daily basis, could that pose a similar problem?

Posted by: Flautist | Jun 21, 2007 2:05:41 PM

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