Medical Aspects of Performance Enhancing

AgentsWhere are the boundaries?

Robert Palinkas, M.D.

I have NO actual or potential conflict of interest in relation to this educational activity or presentation

Most of the agents I discuss have very limited FDA approved use, and all off label use of any agent in this talk is strongly discouraged

But First

Land of the Fighting Illini

Greetings from Illinois

Substances used by athletes to improve their performance◦ Sometimes also used by military personnel to

enhance combat performance A broad group of agents

◦ Steroids (“roids”) are just one type of PED Not all PED’s are illegal

What are performing enhancing agents (PED’s)?

Lean Mass builders Stimulants Painkillers Sedatives Diuretics Blood boosters Masking drugs

The categories of PED’s

Amplify muscle growth and/or reduce reduce fat deposition◦ Anabolic steroids◦ Androgens and Xenoandrogens◦ Human growth hormone◦ HCG◦ Antiestrogens

The Lean Mass Builders

◦ Caffiene◦ Amphetamine◦ Methamphetamine◦ Beta agonists

The Stimulants

Beta blockers

Sedating enhancers

Epogen (EPO)

Blood Boosters

Probenecid epitestosterone

Masking agents

Who uses performance enhancing agents?

Alex Rodriguez- Highest paid NY Yankee

Lance Armstrong- Winner of Several Tours de France?

Arnold Schwarzenneger- Former Governor of California

From T-Nation

From National Institute on Drug Abuse

To improve competitive position◦ For example, body building

To look better◦ For example, easier weight loss

To “feel” better◦ For example, recapture libido from an earlier age

Because of a distorted self image◦ As in the eating disorders

Because of a mental condition◦ As part of obsessive compulsive disorder

Because of financially driven providers◦ Big pharma and entrepreneurial doctors

Why do people use performance enhancing agents

Testosterone synthesized and changed 1935 1952 First use of anabolic steroids at the

Olympics 1976 IOC bans anabolics 1986 IOC begins testing for substances WADA established- the World Anti Doping

Agency

When did this trend begin?

Most use◦ Exercise◦ Diet manipulation◦ Various supplements

Many can be obtained at your local nutrition store Some use

◦ Testosterone or pre-testosterone Usually cycled

◦ Anabolic steroids Usually cycled

◦ Antiestrogens To prevent gynecomastia-SERMs and aromatase inhibitors

◦ HGH or HCG To decrease fat and preserve testicular size

What is the typical bodybuilder using?

Exercise is essential◦ There is no way to build muscle without physical

training Nutrition is essential

◦ Need the substrates for new mass and replacement through catabolism

When both are in the right place, hormonal influences can make a big difference

Building Muscle

Natural Body Building

Phil Heath Winner Mr Olympia 2012

Once Again

Natural Body Building

Phil Heath Winner Mr Olympia 2012 No testing done here

Many patients devise their own hormone regimen or use a regimen someone recommended for them◦ The recommender may be unlicensed◦ Most will use some form of anabolic steroid◦ Many will manipulate their testosterone◦ Some will add HGH◦ Some will use an antiestrogen agent like aromatase

inhibitors The process involves alternating or varying

doses in a cycle or “stack”◦ Combined with variation in diet and exercise

The Hormone Sandbox

The Big Dog

Steroids start with a sterol

A generic sterol Cholesterol

Important organic molecules Present in both plants, animals and fungi Very versatile

◦ Used in cell membranes and as secondary messengers

The Sterols

Androgens◦ Androgenic effects

secondary sex characteristics◦ Anabolic effects

Growth of muscle mass and strength Increased bone density

Male Hormones

Testosterone

Continuous or frequent use is likely to result in testicular atrophy and may result in infertility

Testosterone Use

The path to testosterone and beyond

Have both an androgenic effect and an anabolic effect◦ Some are significantly stronger at stimulating

muscle growth, lipolysis

The Anabolic Steroids

The Common Anabolic Steroids

Structures of the Common Anabolic Steroids

US pharmaceutical manufacturers◦ Rarely

Manufacturers outside the US◦ A significant portion◦ Some are from decent manufacturers

Unlicensed US and foreign chemists◦ The majority

Where do the agents come from?

◦ Some are legal over the counter agents “supplements” exempt from FDA oversight New agents, prehormones

◦ Some are just plain smuggled into the country ◦ Some are purchased on the internet◦ Some are distributed by word of mouth in the

sports community◦ Some are derived from unlicensed “medical”

operations◦ Some are prescribed by licensed providers

incented by profit and sympathy

How do patients get access to HGH, androgens, anabolics?

Mostly Anabolic Steroid Raw ingredients easily obtained Don’t meet FDA standards High Profit

The Underground Labs

I had no difficulty buying 63 pounds of raw material on the internet

Sale was not completed

Start with raw material-testosterone

Set up a basic chem lab

Try to keep it clean

Package the end product

The Pituitary Approach

HCG◦ Strong lipolysis◦ Used for weight loss◦ Some protection

from testicular arophy

HGH◦ Supports lipolysis◦ Strong muscle

growth◦ Protects against

testicular atrophy

The Pituitary Approach

◦ Too numerous to list

Creatine Not so bad Not so effective

NO BCAA Safety Is a huge concern

FDA: 70% of industry violate rules About half are way off on potency 20% contain contaminants 3000 products recalled 2012 6000 complaints filed in 4 years

The Supplements

Focus on insecurities◦ Aging ◦ Waning sexual function◦ Waning strength◦ Weight gain

Can be lucrative◦ At least a 28 Billion dollar industry on

supplements alone

The business side

A Testosterone Ad

An anti-aging ad

A anabolic steroid ad

An HGH Ad

Ad From Antiagenyc for hgh

hGh- enhances growth, reduces fat deposition

Those that are illegal Those that are dangerous Those that come from questionable sources

◦ Possible contamination Those that are injected Those that are outside the medical

orthodoxy

What are the agents of concern?

The most powerful agents are injected

◦ Testosterone◦ HGH◦ Synthol◦ A host of anabolic steroids

The menu of injectables

Also called synthrol An injectable viscous liquid

◦ Used cosmetically to increase muscle size◦ Contains an oil, lidocaine and sometimes alcohols

Synthol

A synthol user

Synthol Muscle Injury

An evolving process◦ Reluctance to impact the financial consequences◦ Reluctance to draw attention or tarnish the sport◦ New chemicals need new tests

Depends on the sport◦ Available resources for testing◦ Strength of the regulatory agency◦ Prevalence of use in the sport

Sports Regulation

Requests for frequent testosterone assays Claims about low testosterone but discordant clinical features

◦ Youth◦ Normal appearing testes◦ Muscular habitus◦ Absence of neurologic-hypothalamic clues◦ Evidence of doctor shopping or different views

Insistence Long lists of associated tests

◦ Estradiol◦ Estriol◦ Progesterone◦ DHEA◦ hGH◦ Prolactin◦ Sex hormone binding globulin

Clues- in males

Out of our scope of practice We follow the orthodoxy

◦ Not alternative medicine Need for fiscal stewardship Draws McKinley staff into medicolegal

involvement◦ Our action:

lab restriction on estradiol testing in men and frequent testosterone assays

Why McKinley at U of I Doesn’t Assist

Some of this is a difference of philosophy◦ Maybe we should all help patients use

medications to resist aging or for cosmesis Or morals

◦ Who are we to judge the way people wish to look But for now

◦ There is no universally accepted treatment regimen approved for this application

In the end