Problems with GH doping in sports

Recent advances in mass spectrometry for the detection of doping

INTRODUCTION

The analysis of doping control samples is preferably performed by mass spectrometry, because obtained results meet the highest analytical standards and ensure an impressive degree of reliability. The advancement in mass spectrometry and all its associated technologies thus allow for continuous improvements in doping control analysis.

AREAS COVERED

Modern mass spectrometric systems have reached a status of increased sensitivity, robustness, and specificity within the last decade. The improved sensitivity in particular has, on the other hand, also led to the detection of drug residues that were attributable to scenarios where the prohibited substances were not administered consciously but rather by the unconscious ingestion of or exposure to contaminated products. These scenarios and their doubtless clarification represent a great challenge. Here, too, modern MS systems and their applications can provide good insights in the interpretation of dose-related metabolism of prohibited substances. In addition to the development of new instruments itself, software-assisted analysis of the sometimes highly complex data is playing an increasingly important role and facilitating the work of doping control laboratories.

EXPERT OPINION

The sensitive analysis and evaluation of a higher number of samples in a shorter time is made possible by the ongoing developments in mass spectrometry.

hGH isoform differential immunoassays applied to blood samples from athletes: decision limits for anti-doping testing

OBJECTIVE

To detect hGH doping in sport, the World Anti-Doping Agency (WADA)-accredited laboratories use the ratio of the concentrations of recombinant hGH ('rec') versus other 'natural' pituitary-derived isoforms of hGH ('pit'), measured with two different kits developed specifically to detect the administration of exogenous hGH. The current joint compliance decision limits (DLs) for ratios derived from these kits, designed so that they would both be exceeded in fewer than 1 in 10,000 samples from non-doping athletes, are based on data accrued in anti-doping labs up to March 2010, and later confirmed with data up to February-March 2011. In April 2013, WADA asked the authors to analyze the now much larger set of ratios collected in routine hGH testing of athletes, and to document in the peer-reviewed literature a statistical procedure for establishing DLs, so that it be re-applied as more data become available.

DESIGN

We examined the variation in the rec/pit ratios obtained for 21,943 screened blood (serum) samples submitted to the WADA accredited laboratories over the period 2009-2013. To fit the relevant sex- and kit-specific centiles of the logs of the ratios, we classified 'rec/pit' ratios based on low 'rec' and 'pit' values as 'negative' and fitted statistical distributions to the remaining log-ratios. The flexible data-driven quantile regression approach allowed us to deal with the fact that the location, scale and shape of the distribution of the modeled 'rec/pit' ratios varied with the concentrations of the 'rec' and 'pit' values. The between-kit correlation of the ratios was included in the fitting of the DLs, and bootstrap samples were used to quantify the estimation error in these limits. We examined the performance of these limits by applying them to the data obtained from investigator-initiated hGH administration studies, and in athletes in a simulated cycling stage race.

RESULTS

The mean and spread of the distribution of the modeled log-ratios depended in different ways on the magnitude of the rec and pit concentrations. Ultimately, however, the estimated limits were almost invariant to the concentrations, and similar to those obtained by fitting simpler (marginal) log-normal and Box-Cox transformed distributions. The estimated limits were similar to the (currently-used) limits fitted to the smaller datasets analyzed previously. In investigator-initiated instances, the limits distinguished recent use of rec-hGH from non-use.

CONCLUSIONS

The distributions of the rec/pit ratios varied as a function of the rec and pit concentrations, but the patterns in their medians and spreads largely canceled each other. Thus, ultimately, the kit- and sex-specific ratio DL obtained from the simpler model was very close to the 'curve of DLs' obtained from the more complex one. Both were close to previously established limits.

Gene doping

Gene doping abuses the legitimate approach of gene therapy. While gene therapy aims to correct genetic disorders by introducing a foreign gene to replace an existing faulty one or by manipulating existing gene(s) to achieve a therapeutic benefit, gene doping employs the same concepts to bestow performance advantages on athletes over their competitors. Recent developments in genetic engineering have contributed significantly to the progress of gene therapy research and currently numerous clinical trials are underway. Some athletes and their staff are probably watching this progress closely. Any gene that plays a role in muscle development, oxygen delivery to tissues, neuromuscular coordination, or even pain control is considered a candidate for gene dopers. Unfortunately, detecting gene doping is technically very difficult because the transgenic proteins expressed by the introduced genes are similar to their endogenous counterparts. Researchers today are racing the clock because assuring the continued integrity of sports competition depends on their ability to develop effective detection strategies in preparation for the 2012 Olympics, which may mark the appearance of genetically modified athletes.

Activation of the GH/IGF-1 axis by CJC-1295, a long-acting GHRH analog, results in serum protein profile changes in normal adult subjects

OBJECTIVE

To identify biomarkers of growth hormone (GH) and insulin-like growth factor 1 (IGF-1) action in human serum.

BACKGROUND

The search for new markers of GH activity has received extensive attention given that the current biomarkers (IGF-1, IGFBP-3 and collagen peptides) show substantial variability in the population, and are not reliably predictive of either the physiologic effects of GH therapy or the detection of GH abuse by athletes. GH releasing hormone (GHRH) is a polypeptide synthesized in the hypothalamus that binds to receptors on pituitary somatotropes to promote the synthesis and release of GH. Serum GH and IGF-1 levels have been shown to increase with administration of GHRH or CJC-1295, a long-acting GHRH analog.

DESIGN

Sera from 11 healthy young adult men before and one week after CJC-1295 injection were analyzed by two-dimensional gel electrophoresis for proteomic changes. Serum proteins displaying significant changes before and after treatment were subsequently identified using mass spectrometry. In addition, correlations between these proteins and GH or IGF-1 levels were evaluated.

RESULTS

Two protein spots that displayed decreased intensities after treatment were identified as an apolipoprotein A1 isoform and a transthyretin isoform. Three protein spots upregulated by CJC-1295 treatment included beta-hemoglobin, a C-terminal fragment of albumin, and a mix of an immunoglobulin fragment and another C-terminal albumin fragment. A linear relationship was found between the spot containing immunoglobulin and albumin fragments and IGF-1 levels.

CONCLUSIONS

Although the molecular mechanisms linking the identified proteins to GH and IGF-1 biological activity remain to be clarified, the results suggest that they represent potential biomarkers of GH and/or IGF-1 action.

Biomarkers: unrealized potential in sports doping analysis

The fight against doping in sport using analytical chemistry is a mature area with a history of approximately 100 years in horse racing and at least 40 years in human sport. Over that period, the techniques used and the breadth of coverage have developed significantly. These improvements in the testing methods have been matched by the increased sophistication of the methods, drugs and therapies available to the cheat and, as a result, testing has been a reactive process constantly adapting to meet new threats. Following the inception of the World Anti-Doping Agency, research into the methods and technologies available for human doping control have received coordinated funding on an international basis. The area of biomarker research has been a major beneficiary of this funding. The aim of this article is to review recent developments in the application of biomarkers to doping control and to assess the impact this could make in the future.

Surface plasmon resonance immuno assays - A perspective

Human growth hormone (GH) represents an extremely challenging task from an anti-doping viewpoint. GH is an endogenously produced substance, present at very low levels in circulation (for the most abundant 22kDa isoform approximately 50pM in plasma and 100fM in urine) either as monomer or homo- and heterodimers, comprises a family of distinct isoforms, and obeys a pulsatile secretion routine that is affected by many different internal and external factors. Upon administration of the recombinant, single-isoform pharmaceutical, the feedback mechanism reduces the endogenous heterogeneity resulting in altered ratios between the different GH isoforms. Thus, measuring the isoform ratios through immuno assays appears the approach of choice. Conventional assays do not provide information on isoform-specific association and dissociation events of the individual primary antibody-isoform or isoform-secondary antibody interactions. This particular information can be obtained using the technology of surface plasmon resonance (SPR) which enables monitoring of biomolecular interactions in a dynamic and label-free setting. In this paper the different aspects of SPR are described, how the technology may be beneficial for understanding today's anti-GH immunoassays, and whether the approach could be employed for measuring GH in the near future.

High-sensitivity chemiluminescence immunoassays for detection of growth hormone doping in sports

BACKGROUND

Recombinant human growth hormone (rhGH) is abused in sports, but adequate routine doping tests are lacking. Analysis of serum hGH isoform composition has been shown to be effective in detecting rhGH doping. We developed and validated selective immunoassays for isoform analysis with potential utility for screening and confirmation in doping tests.

METHODS

Monoclonal antibodies with preference for pituitary hGH (phGH) or rhGH were used to establish 2 pairs of sandwich-type chemiluminescence assays with differential recognition of rhGH (recA and recB) and phGH (pitA and pitB). We analyzed specimens from volunteers before and after administration of rhGH and calculated ratios between the respective rec- and pit-assay results.

RESULTS

Functional sensitivities were <0.05 microg/L, with intra- and interassay imprecision < or =8.4% and < or =13.7%, respectively. In 2 independent cohorts of healthy subjects, rec/pit ratios (median range) were 0.84 (0.09-1.32)/0.81 (0.27-1.21) (recA/pitA) and 0.68 (0.08-1.20)/0.80 (0.25-1.36) (recB/pitB), with no sex difference. In 20 recreational athletes, ratios (median SD) increased after a single injection of rhGH, reaching 350% (73%) (recA/pitA) and 400% (93%) (recB/pitB) of baseline ratios. At a moderate dose (0.033 mg/kg), mean recA/pitA and recB/pitB ratios remained significantly increased for 18 h (men) and 26 h (women). After high-dose rhGH (0.083 mg/kg), mean rec/pit ratios remained increased for 32 h (recA/pitA) and 34 h (recB/pitB) in men and were still increased after 36 h in women.

CONCLUSIONS

Using sensitive chemiluminescence assays with preferential recognition of phGH or rhGH, detection of a single injection of rhGH was possible for up to 36 h.

Gene doping: of mice and men

Gene doping is the newest threat to the spirit of fair play in sports. Its concept stemmed out from legitimate gene therapy trials, but anti-doping authorities fear that they now may be facing a form of doping that is virtually undetectable and extremely appealing to athletes. This paper presents studies that generated mouse models with outstanding physical performance, by manipulating genes such as insulin-like growth factor 1 (IGF-1) or phosphoenolpyruvate carboxykinase (PEPCK), which are likely to be targeted for gene doping. The potential transition from super mice to super athletes will also be discussed, in addition to possible strategies for detection of gene doping.

Secretion of mouse growth hormone by transduced primary human keratinocytes: prospects for an animal model of cutaneous gene therapy

BACKGROUND

Keratinocytes are a very attractive vehicle for ex vivo gene transfer and systemic delivery because proteins secreted by these cells may reach the circulation via a mechanism that mimics the natural process.

METHODS

An efficient retroviral vector (LXSN) encoding the mouse growth hormone gene (mGH) was used to transduce primary human keratinocytes. Organotypic raft cultures were prepared with these genetically modified keratinocytes and were grafted onto immunodeficient dwarf mice (lit/scid).

RESULTS

Transduced keratinocytes presented a high and stable in vitro secretion level of up to 11 microg mGH/10(6)cells/day. Conventional epidermal sheets made with these genetically modified keratinocytes, however, showed a drop in secretion rates of > 80% due to detachment of the epithelium from its substratum. Substitution of conventional grafting methodologies with organotypic raft cultures completely overcame this problem. The stable long-term grafting of such cultures onto lit/scid mice could be followed for more than 4 months, and a significant weight increase over the control group was observed in the first 40 days. Circulating mGH levels revealed a peak of 21 ng/ml just 1 h after grafting but, unfortunately, these levels rapidly fell to baseline values.

CONCLUSIONS

mGH-secreting primary human keratinocytes presented the highest in vitro expression and peak circulatory levels reported to date for a form of GH with this type of cells. Together with previous data showing that excised implants can recover a remarkable fraction of their original in vitro mGH secretion efficiency in culture, the factors that might still hamper the success of this promising model of cutaneous gene therapy are discussed.

Growth hormone, IGF-I and insulin and their abuse in sport

There is widespread anecdotal evidence that growth hormone (GH) is used by athletes for its anabolic and lipolytic properties. Although there is little evidence that GH improves performance in young healthy adults, randomized controlled studies carried out so far are inadequately designed to demonstrate this, not least because GH is often abused in combination with anabolic steroids and insulin. Some of the anabolic actions of GH are mediated through the generation of insulin-like growth factor-I (IGF-I), and it is believed that this is also being abused. Athletes are exposing themselves to potential harm by self-administering large doses of GH, IGF-I and insulin. The effects of excess GH are exemplified by acromegaly. IGF-I may mediate and cause some of these changes, but in addition, IGF-I may lead to profound hypoglycaemia, as indeed can insulin. Although GH is on the World Anti-doping Agency list of banned substances, the detection of abuse with GH is challenging. Two approaches have been developed to detect GH abuse. The first is based on an assessment of the effect of exogenous recombinant human GH on pituitary GH isoforms and the second is based on the measurement of markers of GH action. As a result, GH abuse can be detected with reasonable sensitivity and specificity. Testing for IGF-I and insulin is in its infancy, but the measurement of markers of GH action may also detect IGF-I usage, while urine mass spectroscopy has begun to identify the use of insulin analogues.

Potential Use of Gene Transfer in Athletic Performance Enhancement

After only a short history of three decades from concept to practice, gene therapy has recently been shown to have potential to treat serious human diseases. Despite this success, gene therapy remains in the realm of experimental medicine, and much additional preclinical and clinical study will be necessary for proving the efficacy and safety of this approach in the treatment of diseases in humans. However, a potential complicating factor is that advances in gene transfer technology could be misused to enhance athletic performance in sports, in a practice termed "gene doping". Moreover, gene doping could be a precursor to a broader controversial agenda of human "genetic enhancement" with the potential for a significant long-term impact on society. This review addresses the possible ways in which knowledge and experience gained in gene therapy in animals and humans may be abused for enhancing sporting prowess. We provide an overview of recent progress in gene therapy, with potential application to gene doping and with the major focus on candidate performance-enhancement genes. We also discuss the current status of preclinical studies and of clinical trials that use these genes for therapeutic purposes. Current knowledge about the association between the natural "genetic make-up" of humans and their physical characteristics and performance potential is also presented. We address issues associated with the safety of gene transfer technologies in humans, especially when used outside a strictly controlled clinical setting, and the obstacles to translating gene transfer strategies from animal studies to humans. We also address the need for development and implementation of measures to prevent abuse of gene transfer technologies, and to pursue research on strategies for its detection in order to discourage this malpractice among athletes.

Abuse of growth hormone among young athletes

The underground abuse of growth hormone (GH) among young athletes presents a challenge to medical professionals. Health care professionals providing knowledgeable guidance regarding healthy ways to improve performance and appearance, as well as accurate information regarding substances' perceived benefits, risks, and unknown qualities, is invaluable to the young athlete. Further research focused on the profile and motivation of young people who use GH is essential to understanding and intervening better with those who use these substances.

A rapid surface plasmon resonance (SPR) biosensor immunoassay for screening of somatotropins in injection preparations

The use of growth hormones (recombinant somatotropins (rSTs)) is approved in several countries, e.g. the USA, Brazil and Australia to enhance growth or lactating performances of livestock. Their use in the EU is banned, however, due to the widespread application, the illegal use within the EU cannot be excluded. To screen for rSTs in injection preparations, a biosensor immunoassay (BIA) using surface plasmon resonance (SPR) technology was developed. Compared to existing analysis methods for rSTs, like radio immunoassay (RIA) and enzyme-linked immunosorbent assay (ELISA), this technique provides a rapid (7 min) alternative. A direct BIA was compared to an indirect (inhibition) BIA and the performances of several antibodies against (r)STs were compared in the indirect BIA. In the final inhibition assay, using rabbit anti-bovine rST, extracts from several injection preparations were shown to contain bovine rST (rbST). The limit of detection for rbST in the assay is 0.008 microg mL(-1) which is far below the expected concentrations in injection preparations. Although the cross-reactivities for STs of other species were low, screening of injection preparations for porcine, equine and human ST was feasible through the analysis of less diluted extracts. Tryptic digestion followed by nano-electrospray liquid chromatography-ion trap tandem mass spectrometry (nano-LC-MS/MS) was used to identify STs.

Doping in the recombinant era: strategies and counterstrategies

Advances in recombinant DNA technology have created one of the most powerful weapons in the current doping arsenal: recombinant proteins [Sweeney HL. Gene doping. Sci Am 2004;291:62-9; Unal M, Ozer Unal D. Gene doping in sports. Sports Med 2004;34:357-62]. Recombinant erythropoietin (EPO) and human growth hormone (hGH) are currently being abused but are fortunately detectable either directly by employing isoelectric focusing and immunoassays or indirectly by assessing changes in selected hematopoietic parameters. The detection is technically demanding due to the extent of similarity between the recombinant proteins and their endogenous counterparts. Another issue facing detection efforts is the speed and conditions at which blood samples are collected and analyzed in a sports setting. Recently, gene doping, which stemmed out of legitimate gene therapy trials, has emerged as the next level of doping. Erythropoietin (EPO), human growth hormone (hGH), insulin-like growth factor-1 (IGF-1), peroxisome proliferator-activated receptor-delta (PPAR delta), and myostatin inhibitor genes have been identified as primary targets for doping. Sports clinical scientists today are racing against the clock because assuring the continued integrity of sports competition depends on their ability to outpace the efforts of dopers by developing new detection strategies.

Massspectrometrical analysis of recombinant human growth hormone Norditropin® reveals amino acid exchange at M14_V14 rhGH

Recombinant human growth hormone (rhGH) is used for the treatment of several disorders. Structural integrity of rhGH is of critical importance for its clinical use and modifications thereof may act as markers in situations such as rhGH doping, as illegal rhGH-abuse in sports is of increasing interest. In the current study we investigated homogeneity of Norditropin, a recombinant human growth hormone frequently used in medicine, expressed in E. coli, strain MC1061. The most recent proteomics technologies including 2-DE, MALDI-MS followed by MALDI-MS/MS and LC-MS followed by LC-MS/MS were used for the characterisation of rhGH. MALDI-TOF-TOF and electrospray LC-MS analysis revealed one major protein with an average molecular mass of 22 126.0 Da and some additional minor components. Electrospray LC-MS/MS of the enzymatically digested Norditropin sample showed deamidation of N(12)N(149) and N(159), oxidation of M(14), M(125) and M(170) and one amino acid exchange V(14) for M(14) present in <1% of Norditropin. While deamidation and oxidation may be due to technical reasons, the single amino acid exchange may reflect infidelity of translation rather than codon usage and copy editing by E. coli.

Growth hormone and connective tissue in exercise

Over the last few years, growth hormone (GH) has become increasingly popular as doping within different sports. However, the precise mechanisms behind the ergogenic (performance enhancing) effects of GH in athletes are still being debated. Besides a well-documented stimulatory effect of GH on carbohydrate and fatty acid metabolism, and a possible anabolic effect on myofibrillar muscle protein, we suggest a role for GH as an anabolic agent in connective tissue in human skeletal muscle and tendon. Given the importance of the connective tissue for the function of skeletal muscle and tendon, a strengthening effect of GH on connective tissue could fit with the ergogenic effect of GH experienced by athletes. This review examines the endogenous secretion of GH and its mediators in relation to exercise. Furthermore, we consider the effect of endogenous GH and administered recombinant human GH (rhGH) on both myofibrillar and connective tissue protein synthesis, thus offering an alternative explanation for the ergogenic effect of GH. Finally, we suggest a possible therapeutic role for rhGH in clinical management of the frequently suffered injuries in the connective tissue.

Growth hormone abuse: methods of detection

In the past two decades, growth hormone (GH) has been considered as a performance-enhancing drug in the sport world, certainly favoured by the awareness that there is not yet an approved method for detecting its abuse. Because resting or random measurements of plasma GH concentrations per se are meaningless, new methods have been devised to evaluate plasma levels of GH-sensitive substances that are more stable, and hence detectable, than the hormone itself. This review discusses some of the most recently proposed approaches, including a diagnostic algorithm, based on the timed application of different tests, which, collectively, would have a high diagnostic capability.