Update on Steroids and Other Ergogenics
Sports Medicine Rounds
George C. Phillips, MD, FAAP, CAQSM
March 22, 2007
Athletic Performance Enhancement
Greek Olympics (700 B.C.) athletes ate mushrooms
Aztec athletes ate human hearts
Late 1800s European cyclists used heroin, cocaine, and sugar tablets
soaked in ether
Athletic Performance Enhancement
Tom Hicks 1904 Olympic Marathon Champion used brandy and strychnine
Charlie Paddock 1920 Olympic 100-m champion used sherry with raw egg
Modern Regulation of Performance Enhancers
1960 Olympics Danish cyclist Knut Jensen died during the road race
Amphetamine use
1967 Tour de France British cyclist Tommy Simpson died during the race
Amphetamine use
1967 IOC Medical Commission formed
1968 IOC began testing for stimulants
Steroid Flavors
Stanozolol (1962) low estrogenic effects, high oral bioavailability
(Winstrol)
Nandrolone supposedly less effects on hair, prostate, skin (Durabolin)
Trenbolone veterinary steroid with very high binding affinity for
androgen receptors
Oxandrolone (1964) oral delivery, potent for lean muscle mass (Anavar)
Steroid Rescue
Clomiphene inhibits estrogen effects in the pituitary gland; used by
women for infertility (Clomid)
Also used in bodybuilding:
Blocks the estrogenic effects of steroids
Restores natural production of testosterone
Used for recovery at the end of a steroid cycle
Designer Steroids
THG Tetrahydrogestrinone
Completely new compound
Highly androgenic
No estrogenic activity
If not for one U.S. track coach
Anabolic-Androgenic Steroids
Well known ergogenic properties
Increased muscle mass and strength
Studies have documented strength increases up to 20%
Doses taken by users, or abusers, may not match study doses
More recent studies focus on side effects and preventing youth from using
Negative Effects of Steroids
Multiple organ systems are affected
Negative effects on lipid profile
Lowered HDL levels, known since 1980s
Cardiac hypertrophy has been associated with steroid use, but study
results are mixed
Steroids may cause abnormal left ventricular wall motion
Additive effect to resistance exercise
Negative Effects of Steroids
Abnormal effects on RBC mass
Mediated through erythropoietin
Negative effects on bone metabolism
Increased levels of aggression and manic behavior
Varies between athletes at controlled doses
ATLAS Study
~ 3% of junior high students used steroids
Most were multi-sport athletes
Rates of use in high school students 4-12%
With education, adolescent use of steroids dropped, and young athletes
reported being less likely to use
One year after the intervention, actual rates of use did not decline
Testing for Steroids
Testosterone:Epitestosterone (6:1)
Normal is 1-2:1
Use of older steroids, veterinary steroids
Tetrahydrogestrinone
Completely new compound
Highly androgenic, no estrogenic effects
Specifically designed to avoid detection
Human Growth Hormone
Approved uses: endogenous hGH deficiency; short stature due to chronic
renal failure
Off-label uses: Turners syndrome; small for gestational age without
sufficient catch-up growth
Survey of high school sophomores: 5% reported hGH use, associated with
AAS
hGH Effects
Increases uptake of glucose and amino acids by skeletal muscle
Increases protein synthesis
Increases lipolysis
Increases rate of bone growth
hGH Ergogenic/Ergolytic Effects
No improvement in strength, work capacity or other exercise measurements
in controlled studies
Excess hGH clinically correlates with acromegaly, which includes myopathy
Likely explains lack of benefit at study doses
Excess hGH also linked with insulin resistance and cardiomyopathy
hGH Ergogenic/Ergolytic Effects
Study of anecdotal doses of hGH
Some positive effects
Increased protein synthesis, lean body mass
Some negative effects
Increased fasting insulin, insulin resistance
No change in % body fat or performance measurements after 4 weeks of use
Ethics of hGH Use
Proposed use for idiopathic short stature
Could result in the ever-shifting 3rd %ile
What about the 510 basketball player who needs a little help to reach
6?
Testing: endogenous vs. exogenous
Can use markers of bone turnover that have dose-dependent changes with
hGH use
Erythropoietin
Improving oxygen delivery for exercise
Training at altitude
Blood doping requires equipment for transfusion, storage; significant
cost
Blood doping easily discovered with testing
Red blood cell age
Erythropoietin
Erythropoietin is responsible for RBC production
rEPO developed in the late 1980s for patients with anemia secondary to
chronic renal failure
Increases hemoglobin ~11% in healthy adults, as fast as 4 weeks
Also increases VO2max, time-to-exhaustion
Erythropoietin
rEPO works by increasing the total number of RBCs (polycythemia)
Hyperviscosity: thrombotic events
Heart attack, stroke, pulmonary embolus
Deaths of 18 otherwise healthy cyclists between 1997 and 2000 raised
suspicions
rEPO Testing
Initial testing was for hematocrit
Masked by dilution with IV saline
Urine or blood electrophoresis
Must be performed within days of taking rEPO
Now testing for markers linked to rEPO metabolism
Soluble transferrin receptor increases with rEPO abuse
Glutamine
Non-essential amino acid
Purported ergogenic effects:
Increased strength
Faster recovery time
Decreased number of URIs
Prevention of overtraining
Medical uses in recovery from burns, surgery, HIV, inflammatory bowel
disease
Glutamine
No effect on muscle cell differentiation
No increase in lean muscle mass
No improvement in functional measures
1-RM testing
Number of reps to exhaustion
Major increases in LDL and total cholesterol in as little as 90 days
Glutamine
Does not buffer lactic acid
Time for lactic acid equilibration is faster than glutamine metabolism
No consistent effects on recovery times from weightlifting
Does not affect urinary levels of markers of protein metabolism
Glutamine
No effect on total number of white blood cells or total lymphocyte counts
No consistent effect on frequency of URIs
No consistent effects on other measures of immune system function
No benefit to salivary IgA
Mixed effects on IL-6, LAK cells
Dietary Supplement Regulations
Dietary Supplement Health and Education Act of 1994 (DSHEA)
Recognized that nearly one-half of Americans use a nutritional supplement
Touted the multi-billion dollar industry as integral to the U.S.
economy
Created new classification based on stated or advertised intent
Its All in How You Say It
What is the intended use?
Food caffeine in cola drinks
Drug caffeine in headache medicines
Dietary supplement herbal sources of caffeine (guarana)
DSHEA Regulations
1950 court decision - a drug label must include the condition the drug
is to treat
DSHEA allows general claims of health benefits, provided the following:
No claim of specific disease treatment
Disclaimer that the product has not been evaluated by the FDA
DSHEA Regulations
Three primary methods to regulate products
Grandfathering (October 1994)
If a new product, the burden is on the FDA to perform
post-marketing testing
Removal of adulterated products
Good Manufacturing Practices (GMPs) none established in 11 years
Misbranding
DSHEA Regulations
Misbranding has been used for over a century, starting with patent
medications
False product claims
Rare under DSHEA because of language of general health benefits
Failure to disclose product risks when used at labeled or customary doses
Ephedrine
Brand doses ranged from <1 to 216 mg
Some products were synthetic compounds, not herbal compounds
Variability among single lot of multiple brands as much as 137%
Manufacturers are not required to share adverse event reports with the
FDA
Common Performance Enhancers
Nutritional Supplements
Creatine
DHEA
Androstenedione
Beta-hydroxy-beta-methylbutyrate
Alpha-agonists
Caffeine
Ergogenic aids
Anabolic-androgenic steroids
Human growth hormone
Erythropoietin
Alcohol
Marijuana
Cocaine
Methamphetamine
Creatine
Useful for brief, anaerobic events
Linked with increases in muscle mass
Evidence of different potential mechanisms of effect
ATP regeneration
Increased mRNA and growth factors
Utilized by 44% of high school seniors
Creatine
Not everyone benefits from its use
Mixed results in short sprints
Mixed results in sport-specific skills
Evidence some are creatine responders
Anecdotal reports of adverse effects
No long-term safety data
Concern for growth plate injuries
Prohormones
Peak in popularity in 1990s with public knowledge of use by professional
athletes
Estimated use by 2.5% of high schoolers
No published studies of any sports performance improvement
Potential adverse effects on lipid profiles
Clear estrogenic and androgenic effects
Illegal under DSHEA legislation
Caffeine
Most studies involved caffeine-ephedrine compounds, now illegal under
DSHEA
Clearly has a performance benefit, especially for endurance events
IOC threshold for caffeine is the equivalent of 5-6 cups of coffee
Caffeine
5 mg/kg has ergogenic effect
Below the threshold for most athletes
Effect lasts for up to 6 hours
More prominent effect in those who do not normally use caffeine or
abstain for 6 days
Appears to be relatively safe, but there are definite cardiovascular
effects
Use of NSAIDs by Student Athletes
In a study of 604 Indiana high school football players, 75% had used
NSAIDs in the previous 3 months for sport-related reasons.
Of the users, 20% took NSAIDs daily.
(Phillips GC, AAP Grand Rounds 2002)
Reasons for NSAID Use in HS Athletes
When Asked About Supplements
Nothing replaces proper nutrition and strength training.
Dietary supplements are unregulated products you really cannot be 100%
sure of what they actually contain.
For teenagers, there are either few or no studies for supplements, and
most adult studies are short-term studies.
When Asked About Supplements
There are very real side effects to many supplements and ergogenics.
Illegal use of ergogenics catches up with most athletes eventually.
Too many athletes have died from use of dietary supplements and
ergogenics.