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Performance Enhancing Substances

Rishi Bala, MD Fairfax-VCU Sports Medicine Program. Performance Enhancing Substances. Limitless. Modalities. Prevalence of Performance Enhancing Substance. You wanna be Fantastic?. Retrospective Study with N = 3573 Mean age 15.4 Participating in 1 or more sports Results:

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Performance Enhancing Substances

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  1. Rishi Bala, MD Fairfax-VCU Sports Medicine Program Performance Enhancing Substances Adapted from Dr. Dewebers presentation on: Performance Enhancing Substances in the Endurance Athlete

  2. Limitless

  3. Modalities E.

  4. Prevalence of Performance Enhancing Substance You wanna be Fantastic? • Retrospective Study with N = 3573 Mean age 15.4 Participating in 1 or more sports • Results: • 25.8% of participants reported use of 1 or more IOC restricted substances • Intention to use PES was most significant variable • Pressure from athletes peers to gain weight and level playing field is significantly related to the intent to use Goulet et al. Predictors of the Use of PES by Young Athletes. CJSM 2010.

  5. Steroids Analogs of testosterone More than 100 types Forms: Oral Injection Topical (gels, creams) Prevalence of use 2001: 1% in US college athletes 2006: 13% of German fitness center attendees had used in past

  6. Anabolic Steroids Proven • Increase’s in: • Fat-free mass • Body weight • Arm girth • Leg girth • Bench press and squat scores

  7. Anabolic Steroids: Nandrolone • 16 male bodybuilders randomized to ND (weekly IM) or placebo • 8 weeks of exercise and nutrition monitored • 2.2 kg increase in body mass • 2.6 kg increase in fat free mass • 1.4 kg increase in total body water • No changes in bone density, ECW, ICW, and hydration of FFM VanMarken Lichetenbelt WD et al. Bodybuilders’ Body Composition: Effect of Nandrolone. MSSE 2004.

  8. Anabolic Steroids – Disproven • No effect on endurance exercise • Males on treadmill • Eur J Appl Physiology 2006 • VO2max in rats • Med Sci Sports Exer 2004 Baume, N. Effect of multiple oral doses of androgenic anabolic steroids on endurance performance and serum indices of physical stress in healthy male subjects. EJAP, 2006. Georgieva KN. Effcts of nandrolone decanoate on VO2max, running economy and endurance in rats. MSSE 2004.

  9. Anabolic Steroids – Side Effects • Acne, especially on face and back • Stunted growth in teens • Cardiovascular disease, High blood pressure, unhealthy cholesterol changes • Blood clots and stroke • Hepatocellular damage • Headaches, aching joints, and muscle cramps • Increased risk of ligament and tendon injuries • Needle sharing results in higher risk for serious infections like Hepatitis B and C or HIV • Baldness • Psychological disturbance

  10. Risks & Side Effects • Premature baldness • Prostatic hypertrophy • Testicular atrophy • Impotence • Gynecomastia • Breast Shrinkage • Male-type facial and body hair • Deepening of Voice • Dysmenorrhea • Enlarged Clitoris • Female masculinization

  11. Prohormones • Precursors of testosterone • Androstenedione (Andro) • Dehydroepiandrosterone (DHEA) • Androstenediol

  12. Prohormones – The Evidence • No improvement in strength or lean body mass • *Causes positive urine test for steroids

  13. Prohormones - Side Effects • May be similar to anabolic steroids, but probably less frequent.

  14. Prohormone Regulation • Anabolic Steroid Control Act of 2004 • Prohormones classified as controlled substances • Banned • WADA, NCAA, NFL, NHL, NBA, MLS

  15. Future of Steroids • Designer Steroids: • Norbolethone – Anabolic activity 20x’s > • Tetrahydrogestrinone (THG) and Madol (DMT) • Little known, more on the horizon

  16. Human Growth Hormone (hGH) • Produced in the pituitary gland • Through life with decreasing production late in life • Normal 24 hour cycle of production • Not produced at same rate throughout day • Released in pulses • Primarily used out-of-competition • MOA – Increases IGF -1 • Side Effects • – Acromegaly, arthralgia's, gynecomastia, CTS

  17. Insulin Like Growth Factor – I(IGF–I) • IGFs play a central role in skeletal muscle development and regeneration. • IGF-I is one of several insulin-like protein materials including insulin, IGF-I, and IGF-II, • IGF-I is of greatest interest • Essential for post-natal growth (from hGH) • Action is initiated by binding to the cell membrane and activating synthesis of protein in the cell • There are some overlapping functions of Insulin and IGF-I Receptors

  18. Deer Antler Spray

  19. Deer Antler Spray • Velvet like tissue that covers the antlers of male deer, elk, moose • Ground to fine powder • Claim - IGF-1, amino acids, minerals • Anti-Doping Research – shown in animal tests to increase oxygen uptake, as well as red and white blood cell production

  20. Beta-2-Agonists • Physiology • Bronchodilation, increased ventilation • Examples: albuterol, terbutaline, salmeterol, salbutamol and formoterol

  21. Beta-2-Agonists – Proven Effects • Clear benefit in asthma and EIB • Increased ventilation • No increase in performance in NON-asthmatic athletes • Side effects: tremor, tachycardia • Regulation • USADA: prohibited • Exceptions: • Salmeterol(long) • Formoterol (long) • Salbutamol (short) • NCAA: inhalation permitted Clenbuterol: anabolic (25% as effective as anabolic steroids)

  22. Blood Doping • Increasing the number of red blood cells in the body to increase the oxygen carried to muscle • Administration of blood, red blood cells, or related blood products • Erythropoietin • Normally produced by kidney in response to low oxygenation of blood • Stimulates bone marrow to produce red blood cells

  23. Blood Doping – Proven Effects • 7% increase in Hgb • 5% increase in VO2 max • 34% increase in time to exhaustion at 95% VO2 max • 44 sec improvement in 5 mile treadmill run time

  24. Blood Doping – Side Effects • Transfusion reactions • Infections • Increased viscosity of blood • Stroke, MI, PE

  25. Blood Doping - Regulations • Erythropoietin only by prescription • Doping banned by USADA, NCAA • Blood tested for antigens • Ceiling on allowable Hct level at 50

  26. Beta blockers • Physiology • Decreased heart rate, reduced tremor, lower BP • Examples • Atenolol • Metoprolol • Propranolol • Efficacy in sports • Proven improved scores in shooting sports

  27. Beta blockers • Side effects • Hypotension, bronchospasm, bradycardia • Regulation • NCAA: banned in Rifle sports • WADA: banned in… • Archery, autos, billiards, darts, golf, shooting, skiing/snowboarding • Alcohol banned for same reason

  28. Stimulants • Caffeine • Amphetamines • “greenies” • Cocaine • Sympathomimetics • Ephedrine • Pseudoephedrine • Phenylephrine • Phenylpropanolamine (PPA) • Provigil (Modafinil)

  29. Stimulants – Proven Effects • Increases Endurance • Increases use of free fatty acids and triglycerides • Spares muscle glycogen early in exercise • Decreased perceived exhaustion • Enhances Anaerobic Exercise • Decreases: • Time to exhaustion • Perception of exertion • Hypo analgesic effect • Small amount of weight loss

  30. Stimulant Use Prevalence • Ephedrine: • 3.5% in NCAA athletes • Clin J Sports Med 2001 • 12% of HS boys/26% of girls have tried • Med Sci Sports Exer 2002 • Caffeine • 33% of British club track/field athletes • 60% of British club cyclists • Chester N, Int J Sports Med 2008

  31. Caffeine’s Proven Effects • Increased time to fatigue in wide range of lab protocols • Prolonged submaximal (> 90 min) • Sustained high-intensity (20-60 min) • Short-duration supra-max (1-5 min)

  32. Caffeine’s Proven Effects • Likely beneficial in endurance and“stop-n-go”sports • No clear benefit in strength/power events

  33. Caffeine in Endurance Running • 4.2-sec faster 1.5-km • 1-3% faster 5-km • 24-sec faster 8-km • 50-sec faster 10-km military pack march • Improved treadmill time-to-exhaustion in marathoners • No change in 21-km race during high heat stress

  34. Caffeine in Other Sports • Rowing: 1-3% faster 2000m race • Swimming: 24-sec faster 1500m race • Cycling: 3.5% higher mean power in 40km race

  35. Caffeine Dosing • Doses 2-9 mg/kg in studies • 2-5 mg/kg usually effective • 250-500 mg • Cola: 40 mg • Coffee: 100 mg • Tea: 20-100 mg • Red Bull: 115 mg • Vivarin: 200 mg

  36. Caffeinated Sports Drinks • No proven performance benefit • 18-km run times • Pl vs. carb drink vs. carb+150mg caffeine • Consumed 4x in race VanNieuwenhoven MA. Int J Sports Medicine. 2005.

  37. Ephedrine • 78-sec faster 10-km run (with backpack & helmet) vs. placebo • 30-sec faster than caffeine • -0.8 mg/kg • No benefit when added to caffeine Bell DG. MSSE. 2002.

  38. Modafinil • Cycling at 85% VO2max • 22% improvement in time to exhaustion vs. Placebo • 18.3 min vs. 15.6 • Central mechanism: decreased RPE • Dose 4 mg/kg • No side-effect seen Jacobs, I. et al. Effects of acute modafinil ingestion on exercise time to exhaustion. MSSE, 2004.

  39. Stimulants - Side Effects • Anxiety • Dysrhythmias • Hypertension • Hallucinations • Addiction • Death

  40. Amphetamines • Action – increase in neurotransmitter release and decreased uptake • Prolongs the tolerance to anaerobic exercise/metabolism • Side Effects: • Addictive and withdrawal depression • Anxiety, tremors, insomnia, • Confusion/delirium • Tachy, palpitations, hypertension • Heat stroke • Prominent: cycling, football, ice-hockey and baseball

  41. Amphetamines • Adderall, Dexedrine, Dextrostat, ProCentra, Vyvanse • MLB – 2011, 105 players were granted exemptions for Adderall (1 in 10 MLB players)

  42. Stimulant Regulation • Most banned by USADA & NCAA • Ephedrine • Most ADHD meds • Some still allowed (cold meds) • Pseudoephedrine • Phenylephrine • Caffeine • USADA: no longer monitored • NCAA < 15 mcg/ml • 1 cup coffee = 100mg = 1.5 mcg/ml in urine

  43. Diuretics & Urine Manipulators • Can be used to: • Mask urine tests • Quick weight loss • 2008 WADA 436 cases tested + • Examples • Acetazolamide (altitude sickness) • Furosemide (Lasix) • Spironolactone (acne, HF) • Hydrochlorothiazide (Htn) Cadwallader, AB et al. The abuse of diuretics as PES. BJP, 2010.

  44. Creatine • Replenishes ATP in anaerobic exercise • No federal assessment of quality, performance, or safety • Proven to increase lean body mass, strength

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