THE JOURNAL OF FAMILY PRACTICE 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 • Copyright Most 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 Ask about steroid or supplement he was warned about the risks of ana- ❚ What’s really in 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 16 VOL 58, NO 1 / JANUARY 2009 THE JOURNAL OF FAMILY PRACTICE For mass reproduction, content licensing and permissions contact Dowden Health Media. 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 www.jfponline.com VOL 58, NO 1 / JANUARY 2009 17 17_JFP0109 17 12/16/08 12:05:47 PM THE JOURNAL OF FAMILY PRACTICE 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.