Goals. Performance Enhancing Drugs in Youth Sports. Reasons for Use PED. Anabolic Androgenic Steroids

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1 Goals Performance Enhancing Drugs in Youth Sports Updates in Adolescent Sports Medicine James Kinderknecht MD Hospital for Special Surgery Improve understanding of performance enhancing substance used To become familiar with the potential benefits and adverse effects of commonly used performance enhancing substances To understand some potential management strategies WADA definition of PED 2 of 3 criteria to be on banned list Enhances or has the potential to enhance performance Represents a health risk to the athlete Violates the spirit of the sport Reasons for Use Athletic success Financial gain Necessary to be successful Other athletes are using PED false consensus effect General appearance Peer or coach pressure Influence of professional athlete use PED Anabolic steroids Prohormones Selective Androgen Receptor Modulators Stimulants Synthetic Drugs (not true PED) Anabolic Androgenic Steroids Synthetic derivatives of testosterone Anabolic refers to protein synthesis Androgenic refers to stimulation of male secondary sex characteristics Stimulates multiple hormone receptors: androgen, estrogen, progestin, glucocorticoid 1

2 Epidemiology 5 11% of high school males % of high school females have tried anabolic steroids 33% were not athletes 50% used before age 16 More likely to use other substances Use is correlated with low performance in school (chicken and the egg) Anabolic Steroids Efficacy in Performance Enhancement Increased muscle mass and strength Anabolic effects can occur without weight training Aerobic and endurance activities are not enhanced Improves ability to recover Placebo effect Anabolic Steroids Side effects Cardiovascular Hypertension Increased LDL and decreased HDL Hepatic More likely with oral forms Hepatitis, cholestasis, peliosis hepatitis, liver tumors Endocrine Androgenic Virilizing in women Decrease LH/FSH Testicular atrophy Altered spermatogenesis Infertility Increased estrogen Irreversible gynecomastia Anabolic Steroids Side Effects Psychological Increased aggression Libido Cognitive impairment Dependence/Addiction Musculoskeletal Dysplasia of collagen fibrils leading to strains and rupture Early closure of epiphyses PROHORMONES DHEA Androstenedione Growth Hormone IGF 1 2

3 DHEA Precursor to testosterone Produced in adrenal glands and testes Claims: supplemental use will increase testosterone Anabolic Euphoria Increased libido Additional Claims: Boosted immunity Improved memory Cancer prevention DHEA Does it work? Research limited No increase in serum testosterone No change in muscle mass or strength Critics say research was done in men without weight training Androstenedione Increases androstenedione levels No increase in testosterone levels Significant increase in estrogen No increase in muscle strength DHEA/Androstenedione Side Effects Not well known Increased lipids Virilizing in women?side effects secondary to increased estrogen?side effects similar to AAS?Side effects secondary to impurities in products Selective Androgen Receptor Modulators Target androgen receptors in muscle, bone, prostate Can be agonists or antagonists Animal and clinical trials in treatment of wasting syndromes None have been approved for human use SARMs Non steroidal anabolic agent Potential to cause anabolic effects on androgen receptor without androgenic effects Banned by WADA 2008 Banned by Major/Minor Leagues 2009 as Miscellaneous Anabolic Agents 3

4 Andarine Arylproprionamide derived SARM Freely available on Internet for $100 Detectable Positive test Minor League Program 2010 Single A player Had researched SARMs Did not think it was detectable First reported positive test world wide Essential amino acid Annual sales $200 million 2500 metric tons consumed in 1999 Used by 10% high school athletes Used by 56% of NCAA athletes Used by >90% of bodybuilders Mechanism of action Daily requirement = 2 gram /day 95% stored in skeletal muscle (mostly in fast twitch, type II) 2/3 phosphorylated, 1/3 free In reversible equilibrium with phosphocreatine Energy substrate: phosphocreatine donates PO4 for ATP production users hope to push the time until glycolysis ensues. Is it all hype? 5 15% increase in short term repetitive high intensity exercise?beneficial in power sports Some increase strength in weight training Biggest effect is likely related to recovery Minimal differences at 6 weeks compared with controls Responders vs. Non responders Adverse Effects Weight gain (1 2kg)?Renal failure Increased compartment pressures Anecdotal GI cramps secondary to osmotic load Muscle cramps Dehydration 4

5 MaHuang, OTC cold remedies, etc Stimulants 3 billion doses sold in 1999 $1 billion in ephedra products sold in 2000 Banned by IOC, NCAA Mechanism of action Alpha/Beta adrenergic agonist Release of norepinephrine from sympathetic neurons Goals in supplement use: Increased energy, decreased fatigue Decreasing percentage body fat Benefits Used alone, no performance enhancing effects Specifically, no change in strength, time until exhaustion, oxygen uptake, minute ventilation However, caused significant increase in heart rate More likely to be performances enhancing if combined with caffeine although more side effects with CV, GI, and heat dissipation Side effects Hypertension Heat related issues Arrhythmia Stroke Seizure AMI Implicated in 64% of adverse events reported in the U.S. in 2001 Methylhexanamine Initially marketed as nasal decongestant by Eli Lilly Stimulant found in dietary supplements AKA dimethylamylamine (DMAA) Vasoconstrictor Extract in geranium oil, now found in dietary supplements 5

6 Methylhexanamine 5 Jamaicans tested positive by WADA 2009 Since methylhexanamine not on WADA list, claimed should not be penalized Determined to be related compound to banned tuaminoheptane (MLB banned 2010) Positive test Minor League Baseball and now specifically named as stimulant in MLB Jack3D 250 Grams Lemon Lime Supplement Facts Serving Size1 Scoop (5.55 grams) Servings Per Container: 45 Amount Per Serving % Daily Value* Proprietary Blend 4145mg* (ArginineAlpha Ketoglutarate, Monohydrate, Beta Alanine, Caffeine, 1,3 Dimethylamylamine (Geranium [Stem]), Schizandrol A) * Daily Value not established Other Ingredients: Citric Acid, Natural Lemon Lime Flavor, Acesulfame K, Sucralose, Vegetable Stearate, Silicon Dioxide, Chlorophyll (For Coloring). This product is produced in a facility that processes milk and soy ingredients Black Box Warning: This Product Produces An Intense Sensation Of Drive, Focus, Energy, Motiviation & Awareness. In Addition, It Allows For Rapid Increases In Strength, Speed, Power & Endurance. Therefore, Extreme Caution Must Be Exercised & Should Not Be Used By Novice Athletes. Use With Caution Under Strict Dosing Protocols Methylhexanamine Behind the Scenes Patent on Geranamine owned by Proviant Technologies Owned by Patrick Arnold of BALCO fame Has history of slightly modifying banned substances, e.g. THG, to avoid rules Sport/Energy Drinks Introduced in billion cans of Red Bull sold in US 34% ages 18 to 24 Caffeine content is usually at least 500 mg A cup of coffee is 75 to 150 mg Proposed benefits and side effects similar to ephedra Synthetic stimulants Bath Salts Man made related to amphetamines PO or intranasal Deceiving packaging Bath salt but in a moist towelette type package Plant feed, insect repellant, etc Adverse effects Severe paranoia, agitation, tachycardia, elevated BP, chest pain, hallucinations, death K2 Synthetic marijuana First developed by Clemson U. pharmacologist John W. Huffman (Compound JWH 018, not for human consumption) Usually a herbal mixture sprayed with synthetic substances 10x more potent than Tetrahydrocannabinol (THC) Causes lethargy, relaxation, hypotension, tachycardia, vomiting, seizures, hallucinations, paranoia Has not been tested (scientifically) on humans Unregulated, so a wide variety of substances are called K2 6

7 K2 761 calls to Poison Control Centers across US, as of 7/23/10 costs $30 $40 per three gram bag available in head shops, gas stations, the internet 3/21/11 Buy K2 generated 5 million hits 2/11: DEA classifies K2 as Schedule I substance K2 K2 represents a variety of different substances Some catastrophic outcomes like suicide have resulted Have a high degree of suspicion for individuals who appear intoxicated/dependent/withdrawing from THC but have negative drug tests Detectable with urine drug testing but must request Banned substance Management Issues Ask!! Educate yourself Educate the patient Fewer than 20% of physicians had educated children on dangers of PES Screen Take a good history to screen for other high risk behaviors, nutritional issues, propensity to develop heat related illnesses or overuse injuries Questions to Ask Your Patients Do you (friends/teammates) use anything to help you in sports or competition? Do you take any herbs, vitamins, or natural medicines? Do you use anything to help improve your workouts? Do you take supplements to enhance your appearance? Helpful Websites supplements.info.nih.gov 7