On the Wednesday dinner table are two things your family has prepared for you. Your older sister puts a strip of ibuprofen, just bought at the pharmacy at the end of the alley, next to your rice bowl, and tells you to take one tablet on Sunday morning before the start, and another at kilometer 30 to ease the tiredness. Your mother brews a pot of lotus heart tea (tea made from the green embryo inside lotus seeds), because she has seen you tossing and turning these past few nights, and people always say lotus heart helps you sleep. This year you are running the marathon in the leading group of your age category. The race has prize money, and the organizers have announced that they will take doping samples from some of the early finishers.
The strip of tablets and the pot of tea are so familiar that no one thinks to ask a doctor. Yet the tablet touches the kidneys, on the very day the kidneys already have to work hard, and the pot of tea may touch the urine sample bottle after the finish line.
One tablet at the start, one at kilometer 30
Your sister’s advice is to take it preventively. Take it before your legs hurt, so they will not hurt during the run. Ibuprofen belongs to the group of non-steroidal anti-inflammatory drugs, abbreviated in English as NSAIDs, the same group as diclofenac and many other medicines sold over the counter at pharmacies.
This way of taking it has been tested in exactly its own setting. Lipman et al. (2017) randomly divided 89 runners in an 80 km ultra stage (an ultra is a run longer than a marathon) into two groups. One group took ibuprofen 400 mg every 4 hours during the run, the other took a placebo (a tablet that looks identical but contains no drug). Acute kidney injury occurred in 52% of the ibuprofen group and 34% of the placebo group.
A quick read might suggest the trial proved that ibuprofen harms the kidneys. The odds ratio, one way of comparing risk between two groups (a value of 1 means the two groups are the same), was about 2.1. But the confidence interval, the range the true figure most likely lies within, stretched from 0.9 to 5.1, with its lower end still below the mark of 1. So the data cannot yet rule out that the two groups are really the same, and the difference is only a trend, not yet statistically significant. The opposite conclusion, that the drug is harmless, does not stand up either. The upper end of the interval reaches 5.1, so no one has yet proven that the drug is safe for the kidneys. The authors themselves advise runners to think carefully before using it.
The clinic relies on that signal, plus the drug’s mechanism, which the Harrison internal medicine textbook sets out clearly. We do not recommend taking NSAIDs preventively, whether before the start or partway through a long run.
The day the kidneys carry the heaviest load
A long run is already hard on the kidneys by itself. Lecina et al. (2022), in a review of medical events in ultra trail running (running on mountain and hill trails, longer than a marathon), recorded acute kidney injury based on blood creatinine (a test value that shows how well the kidneys are filtering) in 42% of runners, that is, more than 4 out of every 10, usually passing and then clearing up. Lipman’s placebo group did not take a single ibuprofen tablet, yet 34% of them still had it.
NSAIDs make the kidneys receive less blood (Jameson et al., 2018). Hot weather, being short of water, or taking blood pressure medicines of the ACE inhibitor or ARB groups (two commonly used groups of blood pressure medicines; if you are not sure which group you take, ask the doctor who prescribed it) or diuretics makes that risk heavier. The second tablet at kilometer 30, in our view, falls at the least suitable moment. By then you have been sweating for hours, and the sun is already up.
The stomach takes its share too. About 20–50% of endurance athletes have digestive upset while running, such as nausea and vomiting, and NSAIDs make these problems worse (ACSM’s Advanced Exercise Physiology, p. 377). On the benefit side, the sources we checked have no data showing that preventive use helps you run faster or finish in better shape.
NSAIDs still have a proper place. For a fresh ankle sprain, the clinical practice guideline published in the American orthopedic and sports physical therapy journal JOSPT (Martin et al., 2021) accepts short-term use to ease pain and swelling, at recommendation grade C, meaning it is based on weak evidence. Cuthbert, author of the lower-limb textbook of Applied Kinesiology (AK, a way of testing muscle strength by hand to read the state of the body), adds that drugs in this group have not been seen to make sprains heal faster (p. 228). A few days of medicine as prescribed after a fresh injury is quite different from a tablet swallowed before the starting gun when your legs do not hurt at all.
Some people take them because they already have pain and cannot run without a tablet. For them, the first thing to find out is why it hurts, and only then talk about medicine.
Lotus heart in your mother’s pot of tea
The lotus heart your mother brews is the herb Lian zi xin (Nelumbo nucifera plumule) of traditional herbal medicine. When Lin and Hsu (2024) measured higenamine in many herbs in Taiwan, Lian zi xin had the highest content of all the herbs measured.
Higenamine belongs to the beta-2 agonists (a group of stimulants of the same kind as the bronchodilators used to treat asthma) on the Prohibited List of the World Anti-Doping Agency (WADA). The 2026 edition, in force from January 1, 2026, bans this substance at all times, both in and out of competition; its name has been on the list since the 2017 edition. China’s 2026 list also includes higenamine, but only names the active substance and does not list any herbs by name. Which herbs carry it is something runners and prescribers have to know for themselves.
Current data point to nine herbs, from two kinds of measurement (quantitative analysis gives a specific content figure, qualitative analysis only tells whether the substance is present or not):
- Measured quantitatively (Lin and Hsu, 2024): Lian zi xin, Huang bai (Phellodendron bark), Wu zhu yu (Tetradium ruticarpum fruit), Xi xin (Asarum root and rhizome);
- Detected qualitatively in an analysis of 128 Kampo preparations (traditional Japanese medicine, rooted in Chinese herbal medicine) (Sakamoto et al., 2025): Hou po (Magnolia officinalis bark), Sheng ma (Cimicifuga rhizome), Huang lian (Coptis rhizome), Xin yi (Magnolia flower bud), Suan zao ren (Ziziphus jujuba var. spinosa seed).
The two methods are different, so these nine herbs cannot be ranked on a single scale from more to less. The bigger gap lies with the person drinking them. No study has yet measured human urine after drinking a decoction or a pot of tea containing these herbs. We only know they can make a test positive; how large or small the risk is, no one has yet measured as a figure.
Processed Fu zi (Zhi fu zi, Aconitum carmichaelii lateral root, processed) is the hardest to classify. The measurements in Taiwan found no higenamine. The Kampo analysis, however, found coclaurine, a substance that can be converted into higenamine in mice and in human liver microsomes (a fraction extracted from human liver cells, used for test-tube experiments). The Chinese textbook Identification of Chinese Materia Medica (中药鉴定学 / 中藥鑑定學) still places Fu zi in the group containing higenamine (Kang Tingguo, editor-in-chief, p. 54, 189). The data conflict and no conclusion can yet be drawn either way, so competitors who are tested should avoid this herb.
The older people in the family often say herbal medicine is gentle, and however much you drink it does no harm. That saying is about health, whereas a doping laboratory only looks at whether there is higenamine in the sample or not.
A packet of cold medicine, a medicated plaster
With a runny nose in the week before a race, many people immediately buy a packet of cold medicine. Ma huang (Ephedra sinica stem) contains ephedrine and pseudoephedrine, two stimulants that WADA bans in competition when they exceed a concentration threshold. The textbook Chinese Materia Medica (中药学 / 中藥學) states plainly that Ma huang is not to be used by athletes (运动员禁用, p. 150). Some ready-made cold, cough and asthma medicines contain Ma huang or already contain those two substances, so read the ingredients before opening the pack. Ephedrine has a half-life of about 3–6 hours (after each such stretch of hours, the amount of drug in the blood falls by half), so the clinic advises stopping cold medicines containing these two substances at least 1 day before the race.
Medicines used on the skin count too. Ma qian zi (Strychnos nux-vomica seed) contains strychnine, a stimulant banned in competition, and this toxin can be absorbed through the skin. Medicated liniments and plasters for injuries that contain Ma qian zi should therefore all be avoided before a race (Chinese Materia Medica, p. 514–515; Traditional Pharmacy).
Glucocorticoids (corticosteroid drugs, strong anti-inflammatories) in oral and injected form are banned in competition, while NSAIDs are not on the WADA list. If you have just had a corticosteroid injection into a joint, do not run the next day, because the joint is in the middle of treatment and needs rest. The rules of individual races can be stricter. The UTMB race (a major mountain trail race around the Mont Blanc massif in Europe) in 2021, through its QUARTZ program (a program that monitors athletes’ health and medicines), once banned all pain relievers, NSAIDs included, in the 24 hours before and during the race, although the race’s current policy page only refers to the WADA Code. You need to read the rules of the race you are entering.
For community races or private trail races in Vietnam, we have not yet seen any separate doping control rules. Runners in the leading group, with prize money, or holding a federation card should treat the WADA list as applying to them.
Herbal prescriptions for people who will be tested
The clinic prescribes decoctions in ready-to-drink 50 ml pouches, cooked according to each person’s pattern. If you are running a race with doping samples, tell the doctor right when the prescription is being written; do not wait until the final week. For the nine herbs listed above, there is currently no other herb that can replace them. If your prescription needs them, you must stop taking the medicine at least 1 day before race day. Ma huang and processed Fu zi are not prescribed by the doctor for competitors who are tested.
These herbs are not rare in herbal medicine, as they appear in many familiar formulas. Formulas for people who overwork their minds (doing mental work, thinking a lot) and are forgetful, for example, often contain Suan zao ren. With a tonic batch bought on your own at an herb shop, a runner can hardly know what is inside the paper bag.
A strip of tablets on the muscle-testing table
Before muscle testing, the doctor needs to know all the medicines you are taking. Walther, author of the AK textbooks, wrote that medicines can make an AK examination yield no information, or wrong information, and he lists both sedatives and diuretics among them (Basic Procedures, p. 51).
Imagine a runner who takes an ibuprofen tablet with every long run. That person’s psoas, the muscle that lifts the thigh in the swing phase, is working below threshold, meaning it weakens when tested. In Walther’s chart, this muscle is linked to the kidneys (Synopsis, p. 325). The doctor sees this as a hint to order a creatinine test, because the kidneys have to be measured with blood. The muscle itself is dealt with right in the appointment, by re-stimulating the nerve signal or tapping the tendon reflex, then retesting to see whether the muscle now holds its strength.
That person also has a spot of dull, burning pain that has lasted several months, and the tablets relieve it for a few hours. Cuthbert holds that long-lasting burning pain is often due to an imbalance of prostaglandins (a group of substances the body makes itself that take part in causing inflammation and pain), and that temporary relief from NSAIDs is a fairly strong indicator of that imbalance (p. 293). He describes a muscle that is below threshold getting stronger when the patient holds a little powdered mixture of pain relievers in the mouth, while a strong muscle may weaken when tested with a concentrated source of arachidonic acid (a fatty acid the body uses to make prostaglandins) such as lard. From there, the doctor screens essential fatty acids and cofactors (vitamins and minerals that help the body use fatty acids) to find the substance that clears that response (p. 294).
The decoction pouch is also brought into the testing. The patient holds a small sip in the mouth, and the doctor sees how the muscles related to the system being treated change. In the clinic’s experience, this test shows how the body responds to the decoction, but it cannot tell whether there is higenamine in the pouch.
When to see a doctor
Get examined the same day if, after a long race, you pass much less urine, your urine is unusually dark, or your muscles are badly swollen and painful. At that point you need blood tests for muscle and kidneys (Jameson et al., 2018).
Book an appointment before the race season if:
- You have to take pain relievers to be able to run;
- You are taking blood pressure medicines or diuretics and plan to run long distances;
- You are about to run a race with doping samples and are using herbal medicine, cold medicine, medicated plasters or supplement tablets.
On Sunday morning, your sister’s strip of ibuprofen can stay in the drawer, and your mother can put the lotus heart tea away for now. If you are in the group that gets sampled every year, ask the doctor before she brews it again, because higenamine is banned out of competition too.
If you are about to run a race with doping samples, or have got used to having a pain reliever on every long run, book an appointment with Dr. Dinh Ngoc Duc (MD, MSc in Traditional Medicine) a few weeks before the race. That is enough time to change your decoction prescription if needed, and to find out why your legs have to rely on medicine to run. Book a consultation.
Worth keeping
- If your legs do not hurt, do not take ibuprofen or diclofenac “just in case” before the start or partway through a long run;
- If you take blood pressure medicines of the ACE inhibitor or ARB groups, or diuretics, ask your doctor before taking any pain reliever around race day;
- If you are running a race with doping samples, tell the doctor before herbal medicine is prescribed, and ask whether the prescription contains Lian zi xin, Huang bai, Wu zhu yu, Xi xin, Hou po, Sheng ma, Huang lian, Xin yi or Suan zao ren;
- Read the ingredients of cold medicine packets; if they contain ephedrine, pseudoephedrine or Ma huang, stop at least 1 day before the race;
- Do not use medicated liniments or injury plasters containing Ma qian zi in the days before a race;
- Read the rules of the race you are entering on pain relievers and doping control.
References
Sources in Vietnamese
- Trường Đại học Dược Hà Nội, Bộ môn Dược học cổ truyền. 2002. Dược học cổ truyền. Hà Nội: NXB Y học. Tr. 326, 423–426.
Sources in English
- ACSM’s Advanced Exercise Physiology. p. 377.
- Cuthbert S. 2013. Applied Kinesiology: Clinical Techniques for Lower Body Dysfunctions. Gangasas. p. 228, 293–294.
- Jameson JL, Fauci AS, Kasper DL, Hauser SL, Longo DL, Loscalzo J, editors. 2018. Harrison’s Principles of Internal Medicine. 20th ed. New York: McGraw-Hill Education. p. 2145–2149.
- Lecina M, Castellar-Otín C, López-Laval I, Carrasco Páez L, Pradas F. 2022. Acute Kidney Injury and Hyponatremia in Ultra-Trail Racing: A Systematic Review. Medicina (Kaunas). 58(5). doi:10.3390/medicina58050569. PMID: 35629986.
- Lin YA, Hsu MC. 2024. Determination of doping higenamine in Chinese herbal medicines and their concentrated preparations by LC-MS/MS. J Pharm Biomed Anal. 246:116188. doi:10.1016/j.jpba.2024.116188. PMID: 38733761.
- Lipman GS, Shea K, Christensen M, Phillips C, Burns P, Higbee R, et al. 2017. Ibuprofen versus placebo effect on acute kidney injury in ultramarathons: a randomised controlled trial. Emerg Med J. 34(10):637-642. doi:10.1136/emermed-2016-206353. PMID: 28679502.
- Martin RL, Davenport TE, Fraser JJ, Sawdon-Bea J, Carcia CR, Carroll LA, et al. 2021. Ankle Stability and Movement Coordination Impairments: Lateral Ankle Ligament Sprains Revision 2021. J Orthop Sports Phys Ther. 51(4):CPG1-CPG80. doi:10.2519/jospt.2021.0302. PMID: 33789434.
- Sakamoto S, Osaki K, Abe H, Tayama Y, Tsuruta A, Nuntawong P, et al. 2025. Metabolism of coclaurine into the WADA-banned substance higenamine: a doping-relevant analytical evaluation of Kampo extracts. J Nat Med. 79(5):1140-1153. doi:10.1007/s11418-025-01940-4. PMID: 40751788.
- UTMB. 2021 Sep 20. Result UTMB health policy (QUARTZ program) [Internet]. Available from: montblanc.utmb.world/news/Result-UTMB-health-policy.
- UTMB. Anti-doping resources [Internet; current policy]. Available from: verbier.utmb.world/anti-doping-resources.
- Walther DS. 1981. Applied Kinesiology. Vol. I: Basic Procedures and Muscle Testing. Pueblo (CO): Systems DC. p. 51.
- Walther DS. 2000. Applied Kinesiology: Synopsis. 2nd ed. Pueblo (CO): Systems DC. p. 325.
- World Anti-Doping Agency (WADA). 2026. The 2026 Prohibited List (in force 1 January 2026). Available from: https://www.wada-ama.org/sites/default/files/2025-09/2026list_en_final_clean_september_2025.pdf.
Sources in Chinese
- 国家体育总局, 商务部, 国家卫生健康委, 海关总署, 国家药监局. 2025. 2026年兴奋剂目录 (2025年12月30日).
- 康廷国, 主编. 中药鉴定学. 第 54、189 页.
- 钟赣生, 主编. 中药学. 第 150、514–515 页.
