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Where are the boundaries? Robert Palinkas, M.D.. I have NO actual or potential conflict of interest...
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Transcript of Where are the boundaries? Robert Palinkas, M.D.. I have NO actual or potential conflict of interest...
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Medical Aspects of Performance Enhancing
AgentsWhere are the boundaries?
Robert Palinkas, M.D.
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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
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Land of the Fighting Illini
Greetings from Illinois
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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)?
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Lean Mass builders Stimulants Painkillers Sedatives Diuretics Blood boosters Masking drugs
The categories of PED’s
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Amplify muscle growth and/or reduce reduce fat deposition◦ Anabolic steroids◦ Androgens and Xenoandrogens◦ Human growth hormone◦ HCG◦ Antiestrogens
The Lean Mass Builders
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◦ Caffiene◦ Amphetamine◦ Methamphetamine◦ Beta agonists
The Stimulants
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Beta blockers
Sedating enhancers
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Epogen (EPO)
Blood Boosters
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Probenecid epitestosterone
Masking agents
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Who uses performance enhancing agents?
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Alex Rodriguez- Highest paid NY Yankee
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Lance Armstrong- Winner of Several Tours de France?
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Arnold Schwarzenneger- Former Governor of California
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From T-Nation
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From National Institute on Drug Abuse
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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
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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?
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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?
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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
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Natural Body Building
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Phil Heath Winner Mr Olympia 2012
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Once Again
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Natural Body Building
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Phil Heath Winner Mr Olympia 2012 No testing done here
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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
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The Big Dog
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Steroids start with a sterol
A generic sterol Cholesterol
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Important organic molecules Present in both plants, animals and fungi Very versatile
◦ Used in cell membranes and as secondary messengers
The Sterols
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Androgens◦ Androgenic effects
secondary sex characteristics◦ Anabolic effects
Growth of muscle mass and strength Increased bone density
Male Hormones
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Testosterone
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Continuous or frequent use is likely to result in testicular atrophy and may result in infertility
Testosterone Use
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The path to testosterone and beyond
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Have both an androgenic effect and an anabolic effect◦ Some are significantly stronger at stimulating
muscle growth, lipolysis
The Anabolic Steroids
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The Common Anabolic Steroids
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Structures of the Common Anabolic Steroids
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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?
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◦ 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?
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Mostly Anabolic Steroid Raw ingredients easily obtained Don’t meet FDA standards High Profit
The Underground Labs
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I had no difficulty buying 63 pounds of raw material on the internet
Sale was not completed
Start with raw material-testosterone
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Set up a basic chem lab
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Try to keep it clean
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Package the end product
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The Pituitary Approach
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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
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◦ 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
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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
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A Testosterone Ad
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An anti-aging ad
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A anabolic steroid ad
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An HGH Ad
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Ad From Antiagenyc for hgh
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hGh- enhances growth, reduces fat deposition
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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?
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The most powerful agents are injected
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◦ Testosterone◦ HGH◦ Synthol◦ A host of anabolic steroids
The menu of injectables
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Also called synthrol An injectable viscous liquid
◦ Used cosmetically to increase muscle size◦ Contains an oil, lidocaine and sometimes alcohols
Synthol
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A synthol user
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Synthol Muscle Injury
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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
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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
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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
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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