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