Medications and Ergogenic Aids



Medications and Ergogenic Aids


Scott Flinn

Andrew J. McMarlin



OVERVIEW



  • Many athletes self-medicate using various pharmacologic or nutritional substances in an effort to improve performance and speed recovery from injury. For example, over-the-counter anti-inflammatory medications are often used to limit pain and inflammation in an effort to reduce swelling, limit inflammation, and presumably speed healing from injury.


  • Other substances, some of which may be illegal, are used specifically in an effort to improve workload and performance.






EVALUATING ERGOGENIC AIDS



  • Objective evaluations of ergogenic aids are often difficult to perform. Additionally, the scientific literature usually differs significantly from the advertising on many products (13).


  • There is no burden of proof on the manufacturer to prove efficacy or product content like there is for drugs (23).


  • Products may contain lower amounts of the product than those listed on the label, with some products having zero amount of the supposedly ergogenic substance, whereas others may be contaminated by the previous drug manufactured in the equipment (55).


  • Furthermore, the placebo effect can have a huge impact on the perceived benefits derived by the user.


EFFICACY OF ERGOGENIC AIDS



  • Ergogenic aids can affect various aspects of physical fitness to improve performance. Six components of fitness that may be affected include aerobic fitness, anaerobic fitness, strength, body composition, psychological factors, and healing of injuries.


  • Aerobic metabolism uses oxygen, whereas anaerobic metabolism does not.


  • Aerobic fitness is the ability to produce work using aerobic metabolism, generally lasting longer than 1 minute and often lasting for hours, and is important especially in endurance events. It comprises two parts: maximal aerobic power and aerobic capacity.


  • Anaerobic fitness is important in activities generally lasting less than 1 minute and is fueled primarily through anaerobic metabolism.


  • Maximum strength, usually measured by the one-repetition maximum, refers to the amount of power that can be generated in a brief burst and is fueled by anaerobic metabolism.


  • Body composition can affect performance by increasing lean muscle mass. More muscle can perform more work, whereas decreasing body fat decreases the inert weight that has to be carried through space to the finish line.


  • Psychological factors may affect performance through various mind-body mechanisms including decreased perceptions of fatigue and pain.



  • Enhancing the healing of injuries and soreness promotes a more rapid return to training and maintenance of fitness.


SAFETY CONSIDERATIONS



  • Ergogenic aids can have side effects like any other substance.


  • Heart attacks, seizures, strokes, coma, and death have been attributed to the use of ergogenic products (13).


  • Injectable products carry the risk of disease transmission if needles are shared.


ETHICAL AND LEGAL CONSIDERATIONS



  • The athletic ideal is winning through natural training, which maximizes native ability and performance. However, this is often not the reality. Athletes are constantly caught in the dilemma of trying to keep up with what their competitors may be trying to do. Many athletes will try ergogenic aids even though the product has not been shown to work, has serious side effects, or is banned by the sport’s governing body ruling over the sport in which the athlete is competing.


  • In an attempt to keep the playing field level, various amateur and professional organizations have instituted drug policies. These policies are targeted toward substances that may be dangerous, illegal, and/or give an unfair competitive advantage. For example, the use of anabolic steroids had become so widespread by the 1964 Olympics that drug testing began at the 1968 Olympic Games in Mexico City, with the National Collegiate Athletic Association (NCAA) following in 1986.


  • The American College of Sports Medicine® (ACSM) and other organizations have taken a position on anabolic steroids stating that they are unethical, they have dangerous side effects, and their use should be deplored (2).








    Table 71.1 Ergogenic Aids, Their Effect on Fitness Components, and Dangerous Side Effects

















































































































    Product


    Aerobic


    Anaerobic


    Strength


    Body Composition


    Psychological


    Healing


    Danger


    Anabolic steroids




    +


    +


    +


    ?


    +


    Androstenedione/DHEA




    +


    +


    +


    ?


    +


    β2-agonist (clenbuterol)


    ?




    ?


    ?



    ?


    Blood doping


    +







    ++


    Caffeine


    +


    +




    ?




    Corticosteroids







    ?


    ?


    Creatine



    +


    ?


    +



    ?



    Ephedrine/amphetamines


    +


    +


    +


    +


    +



    ++


    Gene therapy


    ?


    ?


    ?


    ?


    ?


    ?


    ?


    Growth hormone





    +




    ?


    NSAIDs







    ?


    +


    DHEA, dehydroepiandrosterone; NSAIDs, nonsteroidal anti-inflammatory drugs.



  • The Anabolic Steroids Control Act of 1991 made anabolic steroids a Schedule III controlled substance.


  • Anabolic steroids are not the only substances banned by sports governing bodies such as the International Olympic Committee (IOC), the World Anti-Doping Agency (WADA), and the NCAA. The IOC developed their list in 1967.


  • Because of many doping scandals, the U.S. Anti-Doping Agency (USADA) was formed in 2000 as an independent antidoping organization for Olympic sports in the United States. The list of substances banned by the IOC can be viewed on the WADA Web site at www.wada-ama.org/en/World-Anti-Doping-Program/ (72).




  • Because the lists are continually changing, physicians caring for athletes in these or other organizations should always consult them prior to writing a prescription or suggesting over-the-counter remedies.


  • Testing is usually done by analyzing urine samples through a number of methods, with most confirmatory tests done using gas chromatography/mass spectrometry. In the future, blood or hair samples may be used to detect banned substances. See Chapter 25, Drug Testing.


  • Further discussion of ethical considerations related to supplements, medications, and ergogenic aids can be found in Chapter 2, Ethical Considerations in Sports Medicine.


SPECIFIC ERGOGENIC AIDS



  • Specific ergogenic aids will be reviewed here regarding their efficacy, safety, and use in Olympic and NCAA competition. Table 71.1 gives an overview of many ergogenic aids, their effects on the six fitness components, and their safety.



Anabolic-Androgenic Steroids and Selective Androgen Receptor Modulators


Efficacy



  • Anabolic steroids have both anabolic (tissue-building) and androgenic side effects. Anabolic steroids have been shown to increase lean muscle mass and strength when used with an adequate diet and with progressive weight training. Supraphysiologic doses seem to increase these effects (2,7).


  • There does not appear to be a direct effect on aerobic power or capacity, although decreased healing time may allow for increased training volume.


  • Surveys of anabolic steroid users show increases in the incidence of mood disorders and in aggression.


  • Researchers are developing selective androgen receptor modulators in attempts to achieve anabolic effects in specific tissues without the systemic side effects of older androgenic agents (16).


  • The concordant use of human chorionic gonadotropin along with estrogen blockers may increase athletes’ testosterone levels, maintain normal (3:1) testosterone-to-epitestosterone levels, and minimize androgenic side effects (29).


Safety



  • Anabolic steroids are Schedule III drugs. Legal indications to prescribe and common contraindications to steroids are listed in Table 71.2.


  • Anabolic steroids have a long list of reported side effects, some of which may have been exaggerated in the medical literature.


  • A concerning increase in low-density lipoprotein and decrease in high-density lipoprotein (HDL) by an average of 50% in both male and female users, combined with hypertension, have been shown with no direct link yet to increased cardiovascular mortality (2).


  • Adverse effects have been noted in the liver including jaundice, benign tumors, and, rarely, peliosis hepatis (blood-filled cysts in the liver), which has caused a few fatalities when the cysts ruptured. Causation of malignant liver tumors has not been proven (10).








    Table 71.2 Indications and Contraindications for Anabolic Steroids





























    Indications


    Contraindications


    Primary hypogonadism


    Known or suspected prostate cancer


    Hypogonadotropic hypogonadism


    Breast cancer in females with high Ca2+


    Hereditary angioedema


    Breast cancer in males


    Antithrombin III deficiency


    Nephritis


    Anemia from renal disease


    Pregnancy or nursing


    Catabolic disease such as AIDS



    Delayed-onset puberty



    AIDS, acquired immunodeficiency syndrome.



  • Other side effects include acne, female masculinization (alopecia, hirsutism, clitoromegaly, deepening of the voice) and enhancement of aggression.


  • Physiologic doses of testosterone hasten closure of epiphyses (growth plates). Surveys suggest that 6% of high school football players (and 4% of all high school students) have taken anabolic steroids and that half of them started taking them before age 14 (19).


  • Long-term side effects have been harder to establish a causal relationship.


Legality



  • Steroids are Schedule III controlled substances.


  • Banned by IOC and NCAA (WADA 2011, NCAA 2011), although athletes having certain medical conditions (i.e., bilateral orchiectomy for testicular cancer treatment) may apply for a therapeutic use exemption (TUE).


  • Users attempt to avoid detection by tapering in advance of announced tests, staying within the WADA cutoff of 4:1 urinary testosterone-to-epitestosterone ratio, or using masking agents such as diuretics. Recent development of a hair test may change the way testing is done in the future.


Androstenedione and Dehydroepiandrosterone


Efficacy



  • Androstenedione, a testosterone precursor, is one of the few oral “supplements” that is converted into testosterone when ingested. Despite a serum increase in testosterone and estradiol after high doses of androstenedione, double-blinded studies have failed to demonstrate any significant change in lean body mass or strength (68).


  • Dehydroepiandrosterone (DHEA) is a hormone secreted by the adrenal gland that is a precursor to both androgens and estrogens. DHEA levels peak at puberty and young adulthood and gradually fade as aging progresses. Although the FDA banned the manufacture of DHEA as a drug due to insufficient evidence of efficacy and safety, it continues to be available as a nutritional supplement.


  • Studies showed that physiologic doses (50 mg d−1) and supraphysiologic doses (1,600 mg d−1) of DHEA increased circulating androgen levels in older women but not in older men. DHEA increased androstenedione levels but not testosterone levels and had a small, not statistically significant increase in lean body mass when given at supraphysiologic doses to five young males (61).


  • DHEA did not appear to affect energy or protein metabolism in young males (70). In summary, DHEA does not appear to increase testosterone in young healthy males, and it does not appear to have an ergogenic effect.



Safety



  • Side effects of androstenedione are likely to be similar to anabolic steroids.


  • Short-term use of DHEA has been associated with few side effects, but risks of long-term use are unknown. There is a theoretical risk of prostate and endometrial cancer as well as gynecomastia. DHEA effects on lipids are unknown.


Legality



  • Androstenedione, although banned, currently is not frequently specifically tested (10).


  • DHEA is currently banned by both the NCAA and IOC and is available only as a nutritional supplement in the United States (48,72).


β2-Adrenergic Receptor Agonists


Efficacy



  • β2-adrenergic agonists, such as albuterol and salmeterol, are sympathomimetics and are used widely as bronchodilators for the treatment of many types of asthma, including exercise-induced asthma. Clenbuterol, available by prescription in some countries, is a longer acting β2-agonist that may increase aerobic capacity and decrease body fat.


  • There are no human studies to support athletes’ use of clenbuterol for their potential anabolic effects, either as an anabolic steroid substitute or to prevent some of the muscle loss after cessation of anabolic steroids. Animal studies have shown that clenbuterol in high doses increases lean body mass and decreases adipose tissue (50).


  • However, a study on a relative drug, salbutamol, showed increased quadriceps and hamstring strength, while another showed that 6 weeks of oral albuterol may augment strength gains in isokinetic strength training of the knee (14,42).


  • Taken together, these studies imply that there may be an ergogenic effect of prolonged oral β2-agonists on strength, but no ergogenic effect of short-term administration of inhaled medicines. Confirmatory studies on humans remain to be done regarding their potential anabolic effects.


Safety



  • Side effects of β2-agonists are common and similar to other sympathomimetics and include tachycardia, tremor, palpitations, anxiety, headache, anorexia, and insomnia. Serious side effects include dysrhythmias, cardiac muscle hypertrophy, myocardial infarction, or stroke (11,50).


Legality

May 22, 2016 | Posted by in SPORT MEDICINE | Comments Off on Medications and Ergogenic Aids
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