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Marifel Mitzi F. Fernandez, MD Performance-enhancing drugs Robert G. Hosey, MD University of Kentucky snare nonathletes, too Primary Care Sports Medicine Fellowship, Lexington [email protected] High school athletes aren’t the only ones seeking an edge. Here are the red fl ags and unexpected drugs to watch for

Practice recommendations ercises regularly, has been taking some • Multiple adverse effects, including protein shakes and what he refers to as serious cardiovascular effects, a “natural” supplement. His lab work have prompted bans on the sale of shows some elevation in his aspartate anabolic androgenic® Dowdensteroids (AAS) Healthaminotransferase Media (AST) and alanine and their use in competition (A). aminotransferase (ALT), with a negative hepatitis panel. The rest of his metabolic • CopyrightMost users ofFor AAS andpersonal other use panelonly is within normal limits. performance-enhancing drugs are JC was on the track team in high nonathletes or recreational body school, and since graduation has con- builders who begin using these tinued to work out and stay fi t. You ask IN THIS ARTICLE substances in their teen years. him if he takes steroids, and he tells you ❚ What’s really in Ask about steroid or supplement he was warned about the risks of ana- use during yearly physicals (C). bolic androgenic steroids (AAS) in high that supplement? school. He sticks to a “natural” supple- Page 18 Strength of recommendation (SOR) ment, which he buys online or through A Good-quality patient-oriented evidence friends at the gym. Still, you know that ❚ B Inconsistent or limited-quality patient-oriented evidence What to watch for C Consensus, usual practice, opinion, disease-oriented elevated liver enzymes and hypertension Page 19 evidence, case series can be associated with AAS use and that dietary supplements don’t have to meet the same standards the Food and Drug C, a 23-year-old man, is in your Administration (FDA) imposes on drugs. offi ce for evaluation of high blood (See “What’s in that supplement? Labels Jpressure, after failing a commercial don’t always help” on page 18.) You driver’s license exam the previous week. warn him that supplements aren’t always He has been your patient for the past 10 safe, and ask him to bring in his supple- years, and his previous annual physicals ment bottle so you can go over the label have been unremarkable. He is 5'10'' tall, and, possibly, have the contents tested. weighs 209 pounds, and has a muscular build. His blood pressure today is 160/90 and his heart rate is 62 and regular. The ❚ Pursuit of that “edge” rest of his physical exam is normal. extends beyond Olympians He is a nonsmoker, rarely uses al- Even before the start of the modern cohol, and denies illicit drug use. He ex- Olympic games, athletes have used

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16_JFP0109 16 12/16/08 12:05:43 PM ergogenic aids—substances used to en- Anabolic androgenic steroids: hance performance, energy, or work Often paired with energy drinks capacity—to give themselves a “com- Teenagers may refer to AAS as “pumpers,” petitive edge.”1,2 Athletes still use these “gym candy,” or “juice.” Trade names for substances today, and they have been AAS are Dianabol, Anadrol, Deca Dura- joined by nonathletes—some of whom bolin, Parabolin, and Winstrol. AAS are simply want to look good. often used with nutritional supplements A 2004 Internet study of AAS us- like creatine, multivitamins, and energy ers reported that the majority are rec- drinks, in the belief that these regimens reational bodybuilders or nonathletes. will make the user stronger, more muscu- Twenty-fi ve percent of participants in lar, and a better athlete.6,7 this survey reported starting using ste- AAS are synthetic analogues of tes- roids during their teenage years.3 tosterone and come in oral, injectable, An ongoing study of high school and transdermal forms.8,9 At supraphysi- students and young adults indicates ologic doses, testosterone has been found an AAS use prevalence rate of 1.1% to to increase lean body (fat-free) mass and 2.3% in boys and 0.4% to 0.6% in girls. muscle strength in humans.10 The anabol- Approximately 40% of survey partici- ic effects are more pronounced when AAS pants noted that obtaining steroids was are used at higher doses over longer pe- relatively easy.4 riods of time, especially when combined The Centers for Disease Control and with a strength training program.9,10 AAS Prevention (CDC) reports that 4.4% to have also been found to stimulate the 5.7% of boys (grades 9 through 12) production of growth hormone and insu- have used illegal steroids and that 1.9% lin-like growth factor and to counteract to 3.8% of girls have.5 the catabolic effects of cortisol.11 Few AAS users tell their physicians The use and possession of AAS with- of their steroid use. Part of the reason, out a doctor’s prescription is illegal in the of course, is that illegal substance use United States. A majority of AAS users is stigmatized and can lead to prosecu- buy their medications through Internet FAST TRACK tion. Another reason, though, is that suppliers, with some of the drugs being The combination these patients think physicians don’t manufactured overseas or in illicit labs.3 know much about these substances.3 Substandard quality control in manu- of high doses Still other patients, like JC, don’t tell facture poses an increased health risk to of caffeine and because they may not even be aware consumers. ephedrine has that some substances billed as “natural” Adverse effects include injection site a potential for conceal potential dangers. pain, acne, baldness, gynecomastia, tes- For help in spotting patients who ticular atrophy, sexual dysfunction, and life-threatening are using these agents, see “Red fl ags psychological disturbances (also known arrhythmia, for performance-enhancing drug use” as “roid rage”).8,9,11-13 Increases in liver hypertension, on page 20. enzymes with the oral forms of AAS have also been noted.8 In the prepubertal and stroke athlete, premature physeal closure may ❚ Performance-enhancing occur, resulting in permanent short stat- drugs go by many names ure.14 Women who take AAS may have Refi ning your care of patients who are virilization effects, menstrual irregulari- taking performance-enhancing drugs re- ties, and early menopause.11 quires that you know the various names The cardiovascular risks of AAS use these drugs go by, the reason your pa- are substantial. High-dose and long-term tients may be taking them, and the ad- AAS use has been linked to cardiomy- verse effects associated with them. This opathy and sudden death.15-20 Some data review, and the TABLE, will help. suggest the development of accelerated

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Androstat 100, is a precursor of tes- What’s in that supplement? tosterone. This substance is produced in the adrenal glands and gonads.2 Ini- Labels don’t always help tially marketed as a dietary supplement nder the provisions of the 1994 Dietary Supplement Health and anti-aging drug, it was banned by Uand Education Act (DSHEA), supplement manufacturers, the FDA in 2004 because of its potent 26 not the Food and Drug Administration (FDA), are responsible anabolic and androgenic effects. Er- for guaranteeing the safety of their products.52 Components of gogenic use includes promoting muscle the various supplements available are not uniform, and do not building and strength and fat reduction.2 need to be submitted to the FDA for analysis. A study analyzing Studies on healthy young men found no several nutritional supplements revealed the presence of improvement in skeletal muscle adapta- anabolic androgenic steroids (AAS) (14.8% of 634 products) not tion to resistance training with andro- mentioned in the labeling.53 stenedione supplementation for 8 to 12 Using supplements can result in positive drug tests for weeks.27,28 Studies of its effect on increas- banned substances and unwanted side effects. It is important ing blood testosterone levels are confl ict- to ask about supplement use during annual checkups and ing.27,29 Several studies noted an increase sports physicals—especially if the patient has unexplained high in estradiol levels after oral androstene- blood pressure or other somatic complaints. dione supplementation.9,11,27-29 Endocrine pathways with this drug are similar to AAS, and the side effect atherosclerosis with AAS use, leading to profi le is similar as well, although not as hypertension, coronary artery disease pronounced. Larger, long-term studies (CAD), and acute myocardial infarc- are needed to fi ll out this drug’s profi le tion.15,16,18-21 An unfavorable lipid panel and document its effects on the athletes has also been noted, with an increase in who use it. LDL and decreased HDL.18-21 Dehydroepiandrosterone: Tetrahydrogestrinone: Marketed as a “wonder drug” FAST TRACK A “designer” steroid Dehydroepiandrosterone (DHEA), mar- A study analyzing Tetrahydrogestrinone (THG) was ini- keted under the names Prastera, Fidelin, tially developed to avoid detection by and Fluasterone, is another precursor of several nutritional testing protocols current at the time.22-24 testosterone. It is produced in the adrenal supplements This drug has garnered signifi cant media cortex and has weak androgenic proper- revealed the attention in the past few years because ties.2 DHEA is a dietary supplement mar- presence of of scandals involving professional and keted as a “wonder drug” and, like an- Olympic athletes. THG is chemically drostenedione, is advertised to promote anabolic related to 2 other banned steroids, tren- muscle-building and fat-burning. It is also androgenic bolone and gestrinone.22,24 It is used simi- said to have anti-aging properties.11,14 steroids (14.8% of larly to AAS to increase muscle bulk and DHEA has been used by athletes in the enhance performance. It is more hepa- belief that it will increase testosterone lev- 634 products) not totoxic than AAS, with highly potent els and muscle bulk.30 mentioned in the androgenic and progestin properties in In studies done in healthy men, labeling in vitro bioassay studies.22,25 however, even large doses of DHEA Marketing of this agent is banned in (1600 mg/d) did not result in an increase the United States. There are no long-term in testosterone levels. An increase in es- studies of its effectiveness or side effect tradiol levels was noted in elderly men. profi le. Women who supplement with DHEA were found to have increased levels Androstenedione: of testosterone and virilization effects, Initially an anti-aging drug even at small doses (25-50 mg/d).31 Androstenedione, aka Andromax and Because of the risk of these side

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TABLE Performance-enhancing agents: What to watch for

DRUG/SUPPLEMENT ERGOGENIC USE ADVERSE EFFECTS COMMENTS Anabolic androgenic steroids • Increase lean muscle mass Acne, gynecomastia,* • Polypharmacy with other (AAS) at supraphysiologic doses testicular atrophy,* ergogenic agents and • Increase protein synthesis virilization in females,* anti-estrogens is common premature physeal closure, • Stimulate production • Possession and use are elevated liver enzymes, of growth hormone against the law, and athletes increased aggression, found to be using AAS are • Decrease perception hypertension, CAD, sudden banned in competition by of fatigue death sports authorities

Tetrahydrogestrinone (THG) Data on ergogenic use Hepatotoxicity; side effect • Evidence on effectiveness are insuffi cient profi le probably similar to AAS and side effects is insuffi cient • Use is illegal Androstenedione (Andro) Increase testosterone levels Increased estradiol levels, • Confl icting evidence on in order to build muscle feminization, priapism; side how drug affects testosterone effect profi le probably similar levels to AAS • Banned in competition by sports authorities Dehydroepiandrosterone Increase testosterone levels Increased estrogen and • Insuffi cient evidence to (DHEA) for anabolic effects estradiol levels, virilization, support claims as an anabolic increased risk of endometrial or anti-aging agent cancer in females • Sold as a supplement but banned for use in competition Human growth hormone Increase protein synthesis Insulin resistance, premature • Insuffi cient evidence that use (HGH) and muscle mass without physeal closure, acromegaly, enhances athletic performance unwanted androgenic effects, hypertension, cardiomegaly • Expensive decrease body fat • Usually used in addition to AAS • Banned for use in competition Ephedrine Weight loss, increase energy, Anxiety, panic attacks, Banned by the FDA because increase concentration hypertension, tachycardia, of cardiovascular and stroke MI, stroke risk Caffeine Increase alertness and Agitation; potential for Urinary threshold in NCAA energy, weight loss, improve withdrawal symptoms; and Olympic competition endurance hypertension, arrhythmia, and stroke when used with ephedrine or other stimulants Erythropoietin (EPO) Increase oxygen-carrying Pulmonary embolism, MI, Banned in all sports capacity of blood in endurance stroke, development of competition athletes anti-EPO antibodies Creatine Increase production of ATP Muscle cramps, weight gain, • No long-term studies in skeletal muscle during minor gastrointestinal upset available anaerobic exercise • Not recommended in minors • Legally sold as a dietary supplement Sildenafi l Vasodilation, increase Headache, fl ushing, dyspepsia, No action yet to ban in oxygenation and exercise blurring of vision athletic competition capacity ATP, adenosine triphosphate; CAD, coronary artery disease; FDA, Food and Drug Administration; MI, myocardial infarction; NCAA, National Collegiate Athletic Association. * These adverse effects may be irreversible.

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herb ma huang. It goes by many names, Red fl ags for performance- among them Ma Huang, Bolt-ephedrine, Asia Black 25, Hot Body Ephedra, and enhancing drug use Thin Quick. Its chemical structure is re- lated to amphetamine. Among college • Rapid increase in muscle bulk and loss of body fat athletes, ephedrine and amphetamine use • Unexplained high blood pressure, cardiomyopathy, or is more common in power sports, those arrhythmia in a previously healthy adolescent or young adult requiring increased concentration (eg, ri- • Signs and symptoms of feminization in males or virilization fl e shooting, fencing), ice hockey, and fi eld in females sports.35 Users feel less fatigue, experience • Increased aggression, violent behavior, or insomnia bursts of energy, and lose weight.8,36 • Abnormal lab work, including increases in liver enzymes Users may experience irritability, or hematocrit anxiety, insomnia, and tremors, especial- • Polypharmacy or increased use of medications and dietary ly if stimulants are used in conjunction supplements. with high doses of caffeine.35,37 Ephedrine stimulates the release of norepinephrine, which produces increases in blood pres- effects and the lack of long-term stud- sure, peripheral vascular resistance, and ies, DHEA supplementation is not rec- heart rate. These norepinephrine effects ommended for use by adolescents or are the proposed mechanism for reported women.30 There is no convincing evi- cases of myocardial infarction, cerebral dence to support claims of the anabolic artery vasoconstriction, and stroke asso- and anti-aging effects of DHEA. ciated with ephedrine use.13 Marketing of dietary supplements Human growth hormone: that contain ephedrine has been banned Side effects include hypertension by the FDA because of the stimulant’s po- Human growth hormone (HGH) is an tential for increasing cardiovascular and endogenous pituitary hormone with stroke risks.38 FAST TRACK anabolic functions that increases muscle Viagra is the latest mass without the androgenic side ef- Caffeine: fects. It is used medically for patients May give sprinters a leg up entry in the list of with decreased endogenous levels of GH Caffeine—which is found in everything drugs competitive or dwarfi sm. As an ergogenic aid, it has from coffee to energy tablets and energy athletes may be been found to increase levels of insulin- drinks—increases a person’s energy level. using to try to like growth factors, and the combination In endurance sports, it also increases time leads to increased protein synthesis and to exhaustion.32 Studies in endurance- improve sports muscle mass.32 trained cyclists have shown that caf- performance Side effects of HGH include insulin feine intake reduced leg pain, increased resistance, GH-induced myopathy, and maximal leg force, and lengthened time acromegaly-like effects.11 There have been to fatigue.39,40 A recent study in Australia reports of hypertension, cardiomegaly, also showed that caffeine may improve ventricular hypertrophy, and abnormal intermittent-sprint performance in com- lipids with excessive use.19,33 Premature petitive male athletes.41 physeal closure may occur in the adoles- Serious cardiovascular risks and cent HGH user.8 It’s unclear whether HGH even death have been documented actually enhances sports performance, be- when caffeine has been used with other cause the evidence is insuffi cient.34 stimulants, such as ephedrine or am- phetamines. The combination of high Ephedrine: doses of caffeine and ephedrine has a Used by hockey players potential for life-threatening arrhyth- Ephedrine is a stimulant derived from the mia, hypertension, and stroke.42 Other

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psychomotor side effects include anxi- have been found to increase creatine ety, irritability, tremor, and the potential stores in muscles.45 In the phosphorylated for withdrawal symptoms.42,43 Because form, creatine serves as a substrate for ad- of caffeine’s stimulant nature, the Inter- enosine triphosphate resynthesis during national Olympic Committee and the intense anaerobic exercise.11,44-46 Numer- National Collegiate Athletic Associa- ous studies support its ergogenic effect tion have set urinary thresholds for its on short-term, intermittent maximal ac- use in competition. tivities such as bodybuilding, swimming, and jumping. Similar benefi ts have not Erythropoietin: been proven for endurance aerobic ac- Promotes endurance tivities, such as long-distance cycling or Erythropoietin (EPO) is a hormone pro- running.46,47 duced in the kidneys that stimulates pro- This supplement is sold in many duction of red blood cells (erythropoi- forms under such names as Rejuvinix, esis). Marketed under the brand names Cell Tech Hardcore, Muscle Marketing, Epogen and Procrit, EPO has legitimate Femme Advantage, and NOZ. Although medical uses. As an ergogenic substance, not recommended for those under age 18, EPO is used to promote endurance by in- creatine is actually used by approximate- creasing the oxygen-carrying capacity of ly 5.6% of high school athletes, with the the blood with the increased red blood highest levels of use (44%) occurring in cell mass. In endurance athletes, the bene- the 11th and 12th grades.48 Reported side fi ts of recombinant erythropoietin (rEpo) effects of creatine include muscle cramps, may last several weeks.23 There is also a weight gain, and some minor gastrointes- practice called “blood doping,” which tinal upset. Long-term studies on creatine is a transfusion prior to competition, to supplementation are still needed. produce the same effect. Adverse effects of EPO use are at- Viagra (that’s right, Viagra) tributed to increased blood viscosity and Viagra (sildenafi l) is the latest entry in thrombotic potential. Pulmonary embo- the list of drugs competitive athletes may FAST TRACK lism, stroke, myocardial infarction, and be using to try to improve sports perfor- The World Anti- sudden death can occur.19 Cases of death mance. The World Anti-Doping Agency due to severe bradycardia, usually oc- is fi nancing a study investigating whether Doping Agency is curring during the night, have also been sildenafi l can create an unfair competi- fi nancing a study reported.23 Development of anti-EPO tive advantage by dilating blood vessels investigating antibodies may also occur, causing para- and increasing oxygen-carrying capac- whether sildenafi l doxical anemia.23 Athletes found to be ity.49 Studies of the impact of sildenafi l using rEPO are banned from competition on exercise capacity of climbers at the can create an by sports-governing organizations. Mt. Everest base camp and on exercise unfair competitive performance during acute hypoxia have advantage Creatine: been published.50,51 Sildenafi l was found Popular among body builders to improve athletic capacity in both. To Creatine is a popular supplement used date, no action has been taken to ban the by athletes and recreational bodybuilders substance in athletic competition. to provide energy to skeletal muscles in short-duration, maximal exercise.44 It is an endogenous substance found mainly ❚ Are your patients using in skeletal muscle and is synthesized by these agents? Ask them the liver from the amino acids glycine, Family physicians need to be alert to the arginine, and methionine.11,44 It is also red fl ags that may indicate steroid use found in meat. and gently explore the full list of medi- Creatine monohydrate supplements cations, over-the-counter products, and

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Health. 2007. Available at: http://monitoringthefu- ture.org/pubs/monographs/overview2007.pdf. Ac- Web resources cessed November 22, 2008. 5. Centers for Disease Control and Prevention. Youth risk behavior surveillance-United States, 2007. www.usantidoping.org MMWR. 2008;57 (SS-4). Available at http://www. cdc.gov/HealthyYouth/yrbs/pdf/yrbss07_mmwr. www.drugfreesport.com pdf. Accessed November 22, 2008. 6. Hoffman J, Faigenbaum A, Ratamess NA, et al. Nu- www.ncaa.org/wps/portal tritional supplementation and anabolic steroid use in www.wada-ama.org adolescents. Med Sci Sports Exerc. 2008;40:15-24. 7. Faigenbaum A, Zaichkowsky L, Gardner DE, et al. www.steroidabuse.org/ Anabolic steroid use by male and female middle school students. Pediatrics. 1998;101:E6. www.usdoj.gov/dea/pubs/abuse/10-steroids.htm 8. Calfee R, Fadale P. Popular ergogenic drugs www.fda.gov/fdac/features/1998/598_guid.html and supplements in young athletes. Pediatrics. 2006;117:e577-589. www.whitehousedrugpolicy.gov/streetterms/default.asp 9. Tokish J, Kocher M, Hawkins R. Ergogenic aids: a review of basic science, performance, side ef- fects, and status in sports. Am J Sports Med. dietary supplements patients may be us- 2004;32:1543-1553. 10. Bhasin S, Storer TW, Berman N, et al. The effects of ing. Take advantage of annual checkups supraphysiologic doses of testosterone on muscle and sports physicals to ask about use of size and strength in normal men. N Engl J Med. 1996;335:1-7. performance-enhancing substances, edu- 11. McDevitt E. Ergogenic drugs in sports. DeLee & cate patients on the risks involved, and Drez’s Orthopaedic Sports Medicine. Philadelphia: emphasize good nutrition and sensible Elsevier Science; 2003:471-483. 12. Kibble M, Ross M. Adverse effects of anabolic ste- exercise routines as healthy ways to build roids in athletes. Clin Pharmpoe. 1987;6:686-692. a strong, attractive physique. 13. Kutscher EC, Lund BC, Perry PJ. Anabolic steroids: a review for the clinician. Sports Med. 2002;32:285- Education was certainly in order for 296. your patient, JC, described at the begin- 14. Blue JG, Lombardo JA. Steroids and steroid-like ning of this article. He thought the dietary compounds. Clin Sports Med. 1999;18:667-689. 15. Rockhold R. Cardiovascular toxicity of anabolic supplement he used was natural and steroids. Ann Rev Pharmacol Toxicol. 1993;33:497- therefore harmless. Not so. It contained 520. potentially dangerous substances, so you 16. Parssinen M, Kujale U, Vartainen E, et al. Increased premature mortality of competitive power lifters FAST TRACK advised him to stop using it. Nutritional suspected to have used anabolic agents. Int J Take advantage of counseling and a vigorous exercise rou- Sports Med. 2000;21:225-227. tine have allowed JC to maintain his fi t- 17. Nieminen MS, Ramo MP, Viitasalo M, et al. Seri- annual checkups ous cardiovascular side effects of large doses of ness ideal. His blood pressure and liver anabolic steroids in weight lifters. Eur Heart J. and sports enzymes returned to normal levels, and 1996;17:1576-1583. 18. Parssinen M, Seppala T. Steroid use and long- physicals to ask he passed his commercial driver’s license term health risks in former athletes. Sports Med. exam. ■ 2002;32:83-94. about use of 19. Dhar R, Stout W, Link MS, et al. Cardiovascular toxicities of performance-enhancing substances in performance- Correspondence sports. Mayo Clin Proc. 2005;80:1307-1315. enhancing Marifel Mitzi F. Fernandez, MD, 600 Woodside Drive, 20. Melchert RB, Welder AA. Cardiovascular effects of Cornell, WI 54732; [email protected] androgenic anabolic steroids. Med Sci Sports Ex- substances erc. 1995;27:1252-1262. Disclosures 21. Sullivan M, Martinez C, Gennis P, et al. The cardiac toxicity of anabolic steroids. Prog Cardiovasc Dis. The authors reported no potential confl icts of interest 1998;41:1-15. relevant to this article. 22. Malvey T, Armsey T. Tetrahydrogestrinone: the dis- covery of a designer steroid. Curr Sports Med Rep. References 2005;4:227-230. 1. De Rose E. Doping in athletes – an update. Clin 23. Noakes TD. Tainted glory – doping and athletic per- Sports Med. 2008;27:107-130. formance. N Engl J Med. 2004;351:847-849. 2. Di Luigi L. Supplements and the endocrine system 24. Fourcroy J. Designer steroids: past, present and in athletes. Clin Sports Med. 2008;27:131-151. future. Curr Opin Endocrinol Diabetes Obes. 2006; 3. Parkinson A, Evans N. Anabolic androgenic ste- 13:306-309. roids: a survey of 500 users. Med Sci Sports Exerc. 25. Death A, McGrath K, Kazlauskas R, et al. Tetrahy- 2006; 38:644-651. drogestrinone is a potent androgen and progestin. J Clin Endocrinol Metabol. 2004;89:2498-2500. 4. National Institute on Drug Abuse. Monitoring the future. National results on adolescent drug use. 26. Center for Food Safety and Applied Nutrition. Food Overview of key fi ndings. National Institutes of and Drug Administration. Questions and Answers.

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Androstenedione. March 11, 2004. Available at: 40. Del Coso J, Estevez E, Mora-Rodriguez R. Caffeine http://www.cfsan.fda.gov/~dms/androqa.html. Ac- effects on short-term performance during pro- cessed November 22, 2008. longed exercise in the heat. Med Sci Sports Exerc. 27. King DS, Sharp RL, Vukovich MD, et al. Effect of 2008;40:744-751. oral androstenedione on serum testosterone & 41. Schneiker KN, Bishop D, Dawson B, et al. Effects adaptations to resistance training in young men. of caffeine on prolonged intermittent-sprint abil- A randomized control trial. JAMA. 1999;281:2020- ity in team sport athletes. Med Sci Sports Exerc. 2028. 2006;38:578-585. 28. Broeder C, Quindry J, Brittingham K, et al. The An- 42. Keisler BD, Armsey TD. Caffeine as an ergogenic dro project. Physiological & hormonal infl uences aid. Curr Sports Med Rep. 2006;5:215-219. of androstenedione supplement in men 35 to 65 years old participating in a high-intensity resistance 43. Rogers N, Dinges D. Caffeine: implications for training program. Arch Intern Med. 2000;160:3093- alertness in athletes. Clin Sport Med. 2005;24:e1- 3104. e13. 29. Leder B, Longcope C, Catlin DH, et al. Oral an- 44. Kraemer W, Volek J. Creatine supplementation. drostenedione administration and serum tes- its role in human performance. Clin Sports Med. tosterone concentrations in young men. JAMA. 1999;18:651-666. 2000;283:779-782. 45. Harris RC, Soderlund K, Hultman E. Elevation of 30. Yesalis C, Bahrke M. Anabolic-androgenic steroids creatine in resting and exercised muscle of normal and related substances. Curr Sports Med Rep. subjects by creatine supplementation. Clin Sci. 2002;1:246-252. 1992;83:367-374. 31. Arlt W, Justl HG, Callies F, et al. Oral dehydroepi- 46. Demant TW, Rhodes EC. Effects of creatine sup- androsterone for adrenal androgen replacement: plementation on exercise performance. Sports pharmacokinetics and peripheral conversion to Med. 1999;28:49-60. androgens and estrogens in young healthy females after dexamethasone suppression. J Clin Endocri- 47. Balsom PD, Harridge S, Soderlund K, et al. Cre- nol Metab. 1998;83:1928-1934. atine supplementation per se does not enhance endurance exercise performance. Acta Physiol 32. Boyce EG. Use and effectiveness of performance- Scand. 1993;149:521-523. enhancing substances. J Pharm Pract. 2003; 16:22-36. 48. Metzl J, Small E, Levine SR, et al. Creatine use 33. Meyers DE, Cuneo RC. Controversies regarding among young athletes. Pediatrics. 2001;108:421- the effects of growth hormone on the heart. Mayo 425. Clin Proc. 2003;78:1521-1526. 49. Longman J. New suspect in sports doping is, 34. Dean H. Does exogenous growth hormone improve no joke, Viagra. The New York Times. Novem- performance? Clin J Sports Med. 2002;12:250- ber 23, 2008. Available at: http://www.nytimes. 253. com/2008/11/23/sports/23viagra.html?scp=2&sq =Viagra&st=cse. Accessed November 23, 2008 35. McDuff DR, Baron D. Substance use in athletics: a sports psychiatry perspective. Clin Sports Med. 50. Ghofrani HA, Reichenberger F, Kohstall MG, et al. 2005;24:885-897. Sildenafi l increased exercise capacity during hy- poxia at low altitudes and at Mt. Everest base camp: 36. Keisler BD, Hosey RG. Ergogenic aids: an update on ephedra. Curr Sports Med Rep. 2005;4:231- a randomized, double-blind, placebo-controlled FAST TRACK 235. crossover trial. Ann Intern Med. 2004;141:169- 177. 37. Sinclair CJ, Geiger JD. Caffeine use in sports. A JC thought the pharmacologic review. J Sports Med Phys Fitness. 51. Hsu AR, Barnholt KE, Grundman NK, et al. Silde- 2000;40:71-79. nafi l improves cardiac output and exercise perfor- dietary supplement mance during acute hypoxia, but not normoxia. J 38. US Food and Drug Administration. Questions and Appl Physiol. 2006;100:2031. he used was natural answers about FDA’s actions on dietary supple- ments containing ephedrine alkaloids. Febru- 52. Kurtzweil P. An FDA guide to dietary supplements. and therefore ary 6, 2004. Available at: http://www.fda.gov/oc/ FDA Consumer. Sept-Oct, 1998. Available at: http:// initiatives/ephedra/february2004/qa_020604.html. www.fda.gov/fdac/features/1998/598_guid.html. harmless. Not so Accessed November 23, 2008. Accessed November 23, 2008. 39. Motl R, O’Connor P, Tubandi L, et al. Effect of caf- 53. Geyer H, Parr M, Mareck U, et al. Analysis of non- feine on leg muscle pain during cycling exercise hormonal nutritional supplements for anabolic-an- among females. Med Sci Sports Exerc. 2006; drogenic steroids—results of an international study. 38:598-604. Int J Sports Med. 2004;25:124-129. Introducing… THE JOURNAL OF FAMILY PRACTICE’S JFP

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