Doping in Athletes – An Update

Performance-Enhancing Drugs in Healthy Athletes: An Umbrella Review of Systematic Reviews and Meta-analyses

CONTEXT

Many clinicians, trainers, and athletes do not have a true understanding of the effects of commonly used performance-enhancing drugs (PEDs) on performance and health.

OBJECTIVE

To provide an evidence-based review of 7 commonly used pharmacological interventions for performance enhancement in athletes.

DATA SOURCES

PubMed and Scopus databases were searched on April 8, 2022.

STUDY SELECTION

Systematic reviews (SRs) and meta-analyses (MAs) assessing the performance-enhancing effects of the following interventions were included: androgenic anabolic steroids (AAS), growth hormone (GH), selective androgen receptor modulators (SARMs), creatine, angiotensin-converting enzyme (ACE)-inhibitors, recombinant human erythropoietin (rHuEPO), and cannabis.

STUDY DESIGN

Umbrella review of SRs and MAs.

LEVEL OF EVIDENCE

Level 4.

DATA EXTRACTION

Primary outcomes collected were (1) body mass, (2) muscle strength, (3) performance, and (4) recovery. Adverse effects were also noted.

RESULTS

A total of 27 papers evaluating 5 pharmacological interventions met inclusion criteria. No studies evaluating SARMs or ACE-inhibitors were included. AAS lead to a 5% to 52% increase in strength and a 0.62 standard mean difference in lean body mass with subsequent lipid derangements. GH alters body composition, without providing a strength or performance benefit, but potential risks include soft tissue edema, fatigue, arthralgias, and carpel tunnel syndrome. Creatine use during resistance training can safely increase total and lean body mass, strength, and performance in high-intensity, short-duration, repetitive tasks. Limited evidence supports rHuEPO benefit on performance despite increases in both VO2max and maximal power output, and severe cardiovascular risks are documented. Cannabis provides no performance benefit and may even impair athletic performance.

CONCLUSION

In young healthy persons and athletes, creatine can safely provide a performance-enhancing benefit when taken in controlled doses. AAS, GH, and rHuEPO are associated with severe adverse events and do not support a performance benefit, despite showing the ability to change bodily composition, strength, and/or physiologic measures. Cannabis may have an ergolytic, instead of ergogenic, effect.

Psychosocial aspects of sports medicine in pediatric athletes: Current concepts in the 21st century

Behavioral aspects of organized sports activity for pediatric athletes are considered in a world consumed with winning at all costs. In the first part of this treatise, we deal with a number of themes faced by our children in their sports play. These concepts include the lure of sports, sports attrition, the mental health of pediatric athletes (i.e., effects of stress, anxiety, depression, suicide in athletes, ADHD and stimulants, coping with injuries, drug use, and eating disorders), violence in sports (i.e., concepts of the abused athlete including sexual abuse), dealing with supervisors (i.e., coaches, parents), peers, the talented athlete, early sports specialization and sports clubs. In the second part of this discussion, we cover ergolytic agents consumed by young athletes in attempts to win at all costs. Sports doping agents covered include anabolic steroids (anabolic-androgenic steroids or AAS), androstenedione, dehydroepiandrostenedione (DHEA), human growth hormone (hGH; also its human recombinant homologue: rhGH), clenbuterol, creatine, gamma hydroxybutyrate (GHB), amphetamines, caffeine and ephedrine. Also considered are blood doping that includes erythropoietin (EPO) and concepts of gene doping. In the last section of this discussion, we look at disabled pediatric athletes that include such concepts as athletes with spinal cord injuries (SCIs), myelomeningocele, cerebral palsy, wheelchair athletes, and amputee athletes; also covered are pediatric athletes with visual impairment, deafness, and those with intellectual disability including Down syndrome. In addition, concepts of autonomic dysreflexia, boosting and atlantoaxial instability are emphasized. We conclude that clinicians and society should protect our precious pediatric athletes who face many challenges in their involvement with organized sports in a world obsessed with winning. There is much we can do to help our young athletes find benefit from sports play while avoiding or blunting negative consequences of organized sport activities.

Genetics and sports performance: the present and future in the identification of talent for sports based on DNA testing

The impact of genetics on physiology and sports performance is one of the most debated research aspects in sports sciences. Nearly 200 genetic polymorphisms have been found to influence sports performance traits, and over 20 polymorphisms may condition the status of the elite athlete. However, with the current evidence, it is certainly too early a stage to determine how to use genotyping as a tool for predicting exercise/sports performance or improving current methods of training. Research on this topic presents methodological limitations such as the lack of measurement of valid exercise performance phenotypes that make the study results difficult to interpret. Additionally, many studies present an insufficient cohort of athletes, or their classification as elite is dubious, which may introduce expectancy effects. Finally, the assessment of a progressively higher number of polymorphisms in the studies and the introduction of new analysis tools, such as the total genotype score (TGS) and genome-wide association studies (GWAS), have produced a considerable advance in the power of the analyses and a change from the study of single variants to determine pathways and systems associated with performance. The purpose of the present study was to comprehensively review evidence on the impact of genetics on endurance- and power-based exercise performance to clearly determine the potential utility of genotyping for detecting sports talent, enhancing training, or preventing exercise-related injuries, and to present an overview of recent research that has attempted to correct the methodological issues found in previous investigations.

Gene doping: Present and future

Being an elite athlete is an extremely coveted position, which can lead an individual to use doping. As knowledge is extended, doping techniques have become increasingly sophisticated, and the newest method of doping is gene doping. This article aims to present an updated bibliographic survey that addresses gene doping between 1983 and 2018. Anti-doping agencies have not yet approved any detection technique for this type of doping. The possibility of eradicating such doping is almost zero mainly because gene therapy advances rapidly. In this scenario, the future of gene doping must be discussed and decided before irreversible limits are exceeded.

Consumption and biochemical impact of commercially available plant-derived nutritional supplements. An observational pilot-study on recreational athletes

BACKGROUND

A growing consumption of natural (plant-derived) dietary supplements with ergogenic aims, with particular regard for ecdysteroids, phytoestrogens and vegetal sterols, has been registered over the last years among "recreational" athletes. The present study was carried out in order to evaluate the real knowledge of plant-derived nutritional supplements among physically active people as well as their real consumption. Additional aim was to evaluate the effects of these supplements on the health profile of the users.

METHODS

Twenty-three trained subjects who habitually used natural dietary supplements, and 30 matched controls were analyzed for plasma biochemical markers and hormonal profile.

RESULTS

The laboratory tests revealed the absence of any sign of organ toxicity/damage in both athletes and controls. On the contrary, hormone profiles revealed marked alterations in 15 (65%) out of the 23 of investigated athletes. Specifically, 10 males presented increased plasma levels of progesterone, 15 subjects presented abnormal estrogen levels, including 5 (2 F and 3 M) presenting a "dramatic" increased estrogen values and 2 two males with increased estrogen levels, increased testosterone levels and associated suppression of luteinizing hormone and follicle-stimulating hormone.

CONCLUSIONS

The results of the present study highlighted that the habitual consumption of plant-derived nutritional supplements is frequently associated with significant hormonal alterations both in male and female subjects. Although these biochemical alterations were not associated with signs or symptoms of organ toxicity/damage at the moment of the study, it cannot be excluded that, in the mid/long-term, these subjects would suffer of health problems secondary to chronic exposure to heavily altered hormonal levels. Further large scale studies are needed to confirm the results of this pilot study as well as to investigate the biological mechanisms at the base of the observed hormonal alterations.

Doping genético e possíveis metodologias de detecção

O doping genético caracteriza-se pelo uso não terapêutico de células, genes e elementos gênicos, ou a modulação da expressão gênica com objetivo de aumentar o desempenho esportivo. Isto somente pode ser realizado através de manipulação gênica. Esta prática dopante caracteriza-se como virtualmente "indetectável", o que representa novos desafios analíticos para sua detecção. Esta revisão apresenta o doping genético e possíveis métodos de detecção para evitar futuras fraudes desportivas.

The development of doping use in high-level cycling: from team-organized doping to advances in the fight against doping

In 1998, the Festina scandal at the Tour de France provided the first proof of widespread doping in professional cycling. This doping scandal marked the end of team-organized doping in professional cycling and ushered in a new period marked by the increasing implementation of anti-doping measures. This article evaluates the impact of the anti-doping rules and tests instituted since the Festina scandal. We adopt a psychosocial approach to analyze the organization of doping and the development of doping attitudes and practices in high-level cycling. Sixteen cyclists were interviewed, of which eight were young, current cyclists and eight were former cyclists who became professionals before the Festina scandal. Our results show that although the fight against doping in the last decade has reduced doping use in high-level cycling, anti-doping measures have also had unexpected effects. The fight against doping in cycling is not over.

Self-admitted behavior and perceived use of performance-enhancing vs psychoactive drugs among competitive athletes

The relationships between projected use, self-reported behavior and attitudes to performance-enhancing (PED) and recreational (RD) drugs were investigated among 82 competitive Hungarian athletes, with 14.6% admitting using PED and 31.7% using RD. Both the observed doping estimations (even those made by non-users) and self-admitted use were considerably higher than the average rate of positive doping tests (2% of all tests). The notable overestimation by PED users (34.6% vs 16.9%) was in keeping with the false consensus effect. A prediction model with attitude and projection to the likelihood of PED use suggested at least a 70% chance of self-involvement of athletes, with responses at or above the median scores (Performance Enhancement Attitude Scale ≥ 60 and estimation ≥ 50%) on the two independent measures. Users overestimated the prevalence of doping in their sport (P=0.007) but not RD use, with the converse holding for RD users' views of doping (P=0.029). PED users also showed a significantly more lenient attitude toward doping (P<0.001). This domain-specific characteristic adds new information to the ongoing research effort in understanding drug-doping co-morbidity. The reasons for elevated in-group projection are discussed, along with the potential application of this phenomenon in doping epidemiology studies.

Micellar liquid chromatography in doping control

The issue of doping control in sport involves the development of reliable analytical procedures and efficient strategies to process a large number of samples in a short period of time. Reversed-phase LC techniques with aqueous-organic mobile phases and MS or diode-array detection yield satisfactory results for the identification of prohibited substances in sport. However, time-consuming sample pretreatment steps are required, which reduces sample throughput. Micellar LC (MLC) that uses hybrid mobile phases of surfactant above its critical micellar concentration and organic solvent has been revealed as an interesting alternative. The surfactant sodium dodecyl sulfate solubilizes the protein components of urine, serum and plasma, which permits their direct injection into the chromatographic system. Only dilution and filtering of the samples may be required. Most MLC analyses are performed in isocratic mode, with short retention times and good selectivity. The sensitivity of MLC allows the detection of a variety of doping substances at least 24-48 h after being administered.

Sports doping in the adolescent: the Faustian conundrum of Hors de Combat

The drive toward success in sports and the need for a cosmetically acceptable appearance have driven many adolescents to take a wide variety of so-called doping substances. The consumption of these chemicals in the hope and hype of improved sports performance, fueled by the easing of government restrictions on their proof of safety and efficacy, has resulted in an explosion of so-called ergogenic products available to our youth. Agents that have been used include anabolic steroids, anabolic-like agents, designer steroids, creatine, protein and amino acid supplements, minerals, antioxidants, stimulants, blood doping, erythropoietin, beta-blockers, and others. The use of these agents has considerable potential to cause physical and psychological damage. Use and misuse of drugs in this sports doping process should be discouraged. This discussion reviews some of the agents that are currently being used. Clinicians providing sports medicine care to youth, whether through anticipatory guidance or direct sports medicine management, should educate their young patients about the hype and hyperbole of these products that may keep them out instead of in the game at considerable financial cost to the unwary consumer.

Possible mechanisms of sudden cardiac death in top athletes: a basic cardiac electrophysiological point of view

Sudden death among athletes is very rare (1:50,000-1:100,000 annually) but it is still 2-4 times more frequent than in the age-matched control population and attracts significant media attention. We propose a mechanism underlying sudden cardiac death in athletes that does not relate to myocardial ischemia but is based on repolarization abnormalities due to potassium channel downregulation and can also be best explained by the concurrent presence of several factors such as cardiac hypertrophy (athlete's heart), and/or hypertrophic cardiomyopathy, increased sympathetic tone, genetic defects, drugs, doping agents, food, or dietary ingredients. These factors together can increase the repolarization inhomogeneity of the heart ("substrate") and an otherwise harmless extrasystole ("trigger") occurring with a very unfortunate timing may sometimes induce life-threatening arrhythmias. The effective and possible prevention of sudden cardiac death requires the development of novel cost effective cardiac electrophysiological screening methods. Athletes identified by these tests as individuals at higher proarrhythmic risk should then be subjected to more costly genetic tests in order to uncover possible underlying genetic causes for alterations in ionic channel structure and/or function.

beta-Adrenergic stimulation

Two groups of substances which stimulate the adrenergic system are listed as prohibited by the World Anti-Doping Agency. Stimulants are prohibited in-competition only and beta(2)-agonists are prohibited in- and out-of-competition. While beta(2)-agonists act directly on the target receptors, sympathomimetic amines can exert their action directly and indirectly. Due to differences in pharmacology but mainly due to differences in administered dose, differences in detection methods between both groups of substances exist although preparation is similar and consists of an extraction at basic pH. Gas chromatography coupled to mass spectrometry has been the detection methodology of choice for several decades. However, the importance of liquid chromatography-mass spectrometry as a preferred detection methodology is rapidly increasing, especially for the detection of beta(2)-agonists and new additions to the list of prohibited stimulants, such as modafinil. Pharmacology, metabolism and detection of both groups of prohibited substances will be discussed.

Anabolic steroids: dependence and complications of chronic use

Anabolic steroids are widely used for doping, in professional and domestic sports. The mechanism of action is not completely understood. It may differ somewhat depending on the specific molecule due to structural differences that influence the specificity of binding with steroid receptors. When used by athletes in training, they can improve performance to levels that cannot be attained by almost any combination of sophisticated nonchemical support by modern sport science. The severity of the undesired effects of anabolic steroids depends on a variety of factors, from the type and combination of them, the dose and duration of administration, as well as the gender of the person taking the drug. Younger individuals and women show greater effects caused by anabolic steroids in terms of performance, but are also at greater risk of side effects. This paper presents a review of the literature concerning the major adverse effects of anabolic steroids, focusing the attention on possible situations of addiction from this category of drugs.