Glucocorticoids in elite sport: current status, controversies and innovative management strategies-a narrative review

Comprehensive analysis of prohibited substances and methods in sports: Unveiling trends, pharmacokinetics, and WADA evolution

This review systematically compiles sports-related drugs, substances, and methodologies based on the most frequently detected findings from prohibited lists published annually by the World Anti-Doping Agency (WADA) between 2003 and 2021. Aligned with structure of the 2023 prohibited list, it covers all proscribed items and details the pharmacokinetics and pharmacodynamics of five representatives from each section. Notably, it explores significant metabolites and metabolic pathways associated with these substances. Adverse analytical findings are summarized in tables for clarity, and the prevalence is visually represented through charts. The review includes a concise historical overview of doping and WADA's role, examining modifications in the prohibited list for an understanding of evolving anti-doping measures.

Asthma and exercise-induced bronchoconstriction in athletes: Diagnosis, treatment, and anti-doping challenges

Athletes often experience lower airway dysfunction, such as asthma and exercise-induced bronchoconstriction (EIB), which affects more than half the athletes in some sports, not least in endurance sports. Symptoms include coughing, wheezing, and breathlessness, alongside airway narrowing, hyperresponsiveness, and inflammation. Early diagnosis and management are essential. Not only because untreated or poorly managed asthma and EIB potentially affects competition performance and training, but also because untreated airway inflammation can result in airway epithelial damage, remodeling, and fibrosis. Asthma and EIB do not hinder performance, as advancements in treatment strategies have made it possible for affected athletes to compete at the highest level. However, practitioners and athletes must ensure that the treatment complies with general guidelines and anti-doping regulations to prevent the risk of a doping sanction because of inadvertently exceeding specified dosing limits. In this review, we describe considerations and challenges in diagnosing and managing athletes with asthma and EIB. We also discuss challenges facing athletes with asthma and EIB, while also being subject to anti-doping regulations.

Glucocorticoids Accelerate Erythropoiesis in Healthy Humans-Should the Use in Sports Be Reevaluated?

PURPOSE

The World Anti-Doping Agency prohibits glucocorticoid administration in competition but not in periods out of competition. Glucocorticoid usage is controversial as it may improve performance, albeit debated. A hitherto undescribed but performance-relevant effect of glucocorticoids in healthy humans is accelerated erythropoiesis. We investigated whether a glucocorticoid injection accelerates erythropoiesis, increases total hemoglobin mass, and improves exercise performance.

METHODS

In a counterbalanced, randomized, double-blinded, placebo-controlled crossover design (3 months washout), 10 well-trained males (peak oxygen uptake, 60 ± 3 mL O 2 ·min -1 ·kg -1 ) were injected with 40 mg triamcinolone acetonide (glucocorticoid group) or saline (placebo group) in the gluteal muscles. Venous blood samples collected before and 7-10 h, 1, 3, 7, 14, and 21 d after treatment were analyzed for hemoglobin concentration and reticulocyte percentage. Hemoglobin mass and mean power output in a 450-kcal time trial were measured before as well as 1 and 3 wk after treatment.

RESULTS

A higher reticulocyte percentage was evident 3 d (19% ± 30%, P < 0.05) and 7 d (48% ± 38%, P < 0.001) after glucocorticoid administration, compared with placebo, whereas hemoglobin concentration was similar between groups. Additionally, hemoglobin mass was higher ( P < 0.05) 7 d (glucocorticoid, 886 ± 104 g; placebo, 872 ± 103 g) and 21 d (glucocorticoid, 879 ± 111 g; placebo, 866 ± 103 g) after glucocorticoid administration compared with placebo. Mean power output was similar between groups 7 d (glucocorticoid, 278 ± 64 W; placebo, 275 ± 62 W) and 21 d (glucocorticoid, 274 ± 62 W; placebo, 275 ± 60 W) after treatment.

CONCLUSIONS

Intramuscular injection of 40 mg triamcinolone acetonide accelerates erythropoiesis and increases hemoglobin mass but does not improve aerobic exercise performance in the present study. The results are important for sport physicians administering glucocorticoids and prompt a reconsideration of glucocorticoid usage in sport.

Self-Declared and Measured Prevalence of Glucocorticoid Use in Polish Athletes

Glucocorticoids (GCs) are included in the list of prohibited substances and methods in sport published annually by the World Anti-Doping Agency (WADA). In its 2022 update, the WADA list prohibits all injectable routes of administration of GCs for use during in-competition periods. Previously, GCs were prohibited in-competition when administered by oral, intravenous, intramuscular, or rectal routes, but local injections (in addition to topical applications) were allowed. This study first investigated the prevalence of GC use by athletes in Poland, declared in 2130 doping control forms, and the related 2130 urine samples analysed at the Polish Anti-Doping Laboratory. Second, the validity of the analytical methodology to detect GCs was evaluated with the updated WADA requirement for substance-specific minimum reporting levels and considering the proposed washout periods. Despite the new regulation in place, the use of 30 different GC preparations were declared in a total of 162 occurrences (8% of the tests) with therapeutic purposes. Laboratory analyses resulted in the presence of GCs in 16 occurrences with only two samples with a concentration triggering an adverse analytical finding. Our study allowed us to confirm that the applied methodology for the determination of GCs in urine samples (ultra-high-performance liquid chromatography–tandem mass spectrometry) remains fully valid after the latter regulation change while the challenge to assess the timing and administration route for GCs persists.

Glucocorticoids and physical performance: A systematic review with meta-analysis of randomized controlled trials

Introduction

This systematic review with meta-analysis investigates the effect of glucocorticoids on maximal and submaximal performance in healthy subjects.

Methods

We searched for randomised controlled trials investigating the effect of glucocorticoids on physical performance in Web of Science, Scopus, Medline, Embase and SportDiscus in March 2021. Risk of bias was assessed with the revised Cochrane Collaboration Risk of Bias Tool (RoB2). Data from random effect models are presented as standardized difference in mean (SDM) with 95% confidence interval. We included 15 studies comprising 175 subjects.

Results

Two studies had high risk of bias. Glucocorticoids had a small positive effect on maximal physical performance compared to placebo (SDM 0.300, 95% CI 0.080 to 0.520) and the SDM for the 13 included comparisons was not heterogeneous (I2= 35%, p = 0.099). Meta regression found no difference in the effect of acute treatment vs. prolonged treatment or oral ingestion vs. inhalation (p > 0.124). In stratified analysis prolonged treatment (SDM 0.428, 95% CI 0.148 to 0.709) and oral ingestion (SDM 0.361, 95% CI 0.124 to 0.598) improved physical performance. Glucocorticoids improved aerobic performance (SDM 0.371, 95% CI 0.173 to 0.569) but not anaerobic performance (p = 0.135). Glucocorticoids did not change energy expenditure during submaximal performance (SDM 0.0.225 95% CI -0.771 to 0.112).

Discussion

This study indicates that glucocorticoids improves maximal performance and aerobic performance. Glucocorticoids did not affect the energy expenditure during submaximal performance. The conclusions are based on relatively few subjects leading to limited statistical power and uncertain estimates. Still, these results are consistent and should be of interest to WADA and anyone concerned about fair play.

Systematic Review Registration

Open Science Framework 2021-04-29 (https://osf.io/fc29t/).

Effect of Glucocorticoids on Athletic Performance: A Systematic Review and Meta-Analysis

OBJECTIVE

To determine the effects of glucocorticoids in enhancing athletic performance.

DESIGN

At least 2 independent reviewers conducted study selection and extracted demographic and outcome data. Relevant outcomes were stratified by administration time frame and the specific type of drug used. Study quality was assessed using the Cochrane Risk-of-Bias tool and the Cochrane Grading of Recommendations Assessment Development and Education scale. Where appropriate, meta-analyses were performed. Data sources: Embase, MEDLINE, and SPORTDiscus were searched from their beginning to April 2020.

PARTICIPANTS

Participants of any sex and training status aged 18 to 65 years were included.

INTERVENTIONS AND MAIN OUTCOME MEASURES

Any type of published randomized controlled trial (RCT) that examined any enhancement in sport as well as aerobic, anaerobic, or body compositional parameters for glucocorticoids compared with placebo.

RESULTS

There is low-to-moderate evidence suggesting that the administration of glucocorticoids may be more beneficial than placebo in enhancing athletic performance. short-term administration of glucocorticoids significantly improved time to exhaustion, maximal force, and total distance travelled. By contrast, acute administration of glucocorticoids predominantly yielded no changes to athletic performance, except for reductions in total work and maximal power output.

CONCLUSIONS

Although there is evidence suggesting glucocorticoids have ergogenic effects, these improvements may differ depending on the specific type of drug, dose, and the administration time frame and are also limited by small sample sizes. Therefore, there is a need for large, high-quality RCTs as this may influence future doping policy and athlete care.

Cardiovascular effects of doping substances, commonly prescribed medications and ergogenic aids in relation to sports: a position statement of the sport cardiology and exercise nucleus of the European Association of Preventive Cardiology

The use of substances and medications with potential cardiovascular effects among those practicing sports and physical activity has progressively increased in recent years. This is also connected to the promotion of physical activity and exercise as core aspects of a healthy lifestyle, which has led also to an increase in sport participation across all ages. In this context, three main users' categories can be identified, (i) professional and amateur athletes using substances to enhance their performance, (ii) people with chronic conditions, which include physical activity and sport in their therapeutic plan, in association with prescribed medications, and (iii) athletes and young individuals using supplements or ergogenic aids to integrate their diet or obtaining a cognitive enhancement effect. All the substances used for these purposes have been reported to have side effects, among whom the cardiovascular consequences are the most dangerous and could lead to cardiac events. The cardiovascular effect depends on the type of substance, the amount, the duration of use, and the individual response to the substances, considering the great variability in responses. This Position Paper reviews the recent literature and represents an update to the previously published Position Paper published in 2006. The objective is to inform physicians, athletes, coaches, and those participating in sport for a health enhancement purpose, about the adverse cardiovascular effects of doping substances, commonly prescribed medications and ergogenic aids, when associated with sport and exercise.

Pharmacological Treatment for Acute Traumatic Musculoskeletal Pain in Athletes

Pain management is a crucial issue for athletes who train and compete at the highest performance levels. There are still evidence gaps for the use of analgesics for sports injuries despite the growing interest in training and competition settings. However, high-quality research is needed to determine the most appropriate and optimal timing and formulations in non-steroidal anti-inflammatory drug and opioid management, particularly given the strictness of anti-doping regulations. Indeed, the role of pharmacological therapy in reducing acute traumatic pain in athletes should still be addressed to minimize the timing of return to sport. Therefore, the aim of this comprehensive review was to summarize the current evidence about pain management in the setting of acute injury in elite athletes, providing the most informed strategy for pain relief and performance recovery.

Recent advances in identifying and utilizing metabolites of selected doping agents in human sports drug testing

Probing for evidence of the administration of prohibited therapeutics, drugs and/or drug candidates as well as the use of methods of doping in doping control samples is a central assignment of anti-doping laboratories. In order to accomplish the desired analytical sensitivity, retrospectivity, and comprehensiveness, a considerable portion of anti-doping research has been invested into studying metabolic biotransformation and elimination profiles of doping agents. As these doping agents include lower molecular mass drugs such as e.g. stimulants and anabolic androgenic steroids, some of which further necessitate the differentiation of their natural/endogenous or xenobiotic origin, but also higher molecular mass substances such as e.g. insulins, growth hormone, or siRNA/anti-sense oligonucleotides, a variety of different strategies towards the identification of employable and informative metabolites have been developed. In this review, approaches supporting the identification, characterization, and implementation of metabolites exemplified by means of selected doping agents into routine doping controls are presented, and challenges as well as solutions reported and published between 2010 and 2020 are discussed.

SporTRIA study-a multicentre trial protocol for excretion kinetics of triamcinolone acetonide following sport-related intra-articular injections in knees: definitions of the washout periods

INTRODUCTION

Intra-articular (IA) and peri-articular glucocorticoid (GC) injections are common in sports medicine. However, from 1 January 2022, all injectable GC routes (including IA administration) will be prohibited in-competition by World Anti-Doping Agency (WADA). Owing to these rules, an IA GC treatment out-of-competition could result in an adverse analytical finding in-competition if the washout period is not clearly defined. The aim of this study is to determine the urinary excretion profile of triamcinolone acetonide following IA injection to strengthen the definition of the washout periods.

METHODS AND ANALYSIS

This is a prospective multicentre trial to include 20 subjects who practice sports for at least 4 hours/week and present a knee disorder requiring IA injection of triamcinolone acetonide for therapeutic purposes. To determine the excretion profile of triamcinolone acetonide in both urine and blood following IA injection of the drug, We will perform 20 urinary tests and 20 dried blood spot tests, two prior to GC injection (baseline) and the last one at 35 days. Analyses will be performed by the French antidoping agency laboratory in accordance with WADA standards and regulations.

ETHICS AND DISSEMINATION

The study protocol was approved by the French ethics committee (CPP Sud Est III-Lyon-2020-070B on 06 October 2020). All subjects will provide written informed consent. The results of this study will be accessible in peer-reviewed publication and be presented at academic conference.

TRIAL REGISTRATION NUMBER

NCT04574232.

Dihydrotestosterone (DHT) rapidly increase after maximal aerobic exercise in healthy males: the lowering effect of phosphodiesterase's type 5 inhibitors on DHT response to exercise-related stress

PURPOSE

Few data exist on dihydrotestosterone (DHT) adaptation to exercise-related stress. The aim of the study was to investigate on serum DHT and other androgens' responses to acute aerobic exercises, and to verify if a long-acting phosphodiesterase's type 5 inhibitors could influence these responses, as previously observed for salivary testosterone.

METHODS

In a double-blind cross over study, 12 healthy trained male volunteers were submitted to both an acute sub-maximal and maximal exercise tests on cycle ergometer, after randomly receiving a two days placebo or tadalafil administration (20 mg, Cialis^®, Ely-Lilly, Indianapolis, IN, USA). Blood sample collections were performed at different time points before and after exercise. Serum DHT, total testosterone (TT), dehydroepiandrosterone sulfate (DHEAS) and luteinizing hormone (LH), were assayed.

RESULTS

Serum DHT increase in placebo treatment immediately post maximal aerobic exercise and return to basal values at 60 min of recovery whereas tadalafil administration significantly reduced the DHT increase after exercise. The values of areas under curves showed the increase of TT after acute sub-maximal and maximal exercise and of DHEAS only after acute maximal aerobic exercise independently from treatment.

CONCLUSIONS

In addition to testosterone, also DHT plays an exercise-related adaptive role during high intensity aerobic exercise, but its rapid useful effects during exercise have to be determined. We hypothesized that the increased androgens secretion during exercise could be mainly related to steroidogenic enzymes modifications in peripheral tissues (i.e., muscles). Moreover, the blunting effect of tadalafil on DHT increase support a possible role of peripheral nitric oxide/GMPc related pathways in influencing physical-stress related DHT metabolism.

Frequency and type of adverse analytical findings in athletics: Differences among disciplines

Athletics is a highly diverse sport that contains a set of disciplines grouped into jumps, throws, races of varying distances, and combined events. From a physiological standpoint, the physical capabilities linked to success are quite different among disciplines, with varying involvements of muscle strength, muscle power, and endurance. Thus, the use of banned substances in athletics might be dictated by physical dimensions of each discipline. Thus, the aim of this investigation was to analyse the number and distribution of adverse analytical findings per drug class in athletic disciplines. The data included in this investigation were gathered from the Anti-Doping Testing Figure Report made available by the World Anti-Doping Agency (from 2016 to 2018). Interestingly, there were no differences in the frequency of adverse findings (overall,~0.95%, range from 0.77 to 1.70%) among disciplines despite long distance runners having the highest number of samples analysed per year (~9812 samples/year). Sprinters and throwers presented abnormally high proportions of adverse analytical findings within the group of anabolic agents (p < 0.01); middle- and long-distance runners presented atypically high proportions of findings related to peptide hormones and growth factors (p < 0.01); racewalkers presented atypically high proportions of banned diuretics and masking agents (p = 0.05). These results suggest that the proportion of athletes that are using banned substances is similar among the different disciplines of athletics. However, there are substantial differences in the class of drugs more commonly used in each discipline. This information can be used to effectively enhance anti-doping testing protocols in athletics.

A novel approach to improve detection of glucocorticoid doping in sport with new guidance for physicians prescribing for athletes

The systemic effect of glucocorticoids (GCs) following injectable routes of administration presents a potential risk to both improving performance and causing harm to health in athletes. This review evaluates the current GC antidoping regulations defined by the World Anti-Doping Agency and presents a novel approach for defining permitted and prohibited use of glucocorticoids in sport based on the pharmacological potential for performance enhancement (PE) and risk of adverse effects on health. Known performance-enhancing doses of glucocorticoids are expressed in terms of cortisol-equivalent doses and thereby the dose associated with a high potential for PE for any GC and route of administration can be derived. Consequently, revised and substance-specific laboratory reporting values are presented to better distinguish between prohibited and permitted use in sport. In addition, washout periods are presented to enable clinicians to prescribe glucocorticoids safely and to avoid the risk of athletes testing positive for a doping test.

Foot and Ankle Injections in Athletes

CONTEXT

Injections are commonly used by health care practitioners to treat foot and ankle injuries in athletes despite ongoing questions regarding efficacy and safety.

EVIDENCE ACQUISITION

An extensive literature review was performed through MEDLINE, Google Scholar, and EBSCOhost from database inception to 2021. Keywords searched were injections, athletes, sports, foot and ankle, corticosteroids, platelet-rich plasma, and placental tissue. Search results included articles written in the English language and encompassed reviews, case series, empirical studies, and basic science articles.

STUDY DESIGN

Clinical review.

LEVEL OF EVIDENCE

Level 4.

RESULTS

Corticosteroids, platelet-rich plasma/autologous blood, anesthetic, and placental tissue injections are commonly used in the treatment of foot and ankle injuries. Primary indications for injections in athletes include plantar fasciitis, Achilles tendinosis, isolated syndesmotic injury, and ankle impingement with varying clinical results.

CONCLUSIONS

Despite promising results from limited case series and comparative studies, the data for safety and efficacy of injections for foot and ankle injuries in athletes remain inconclusive.

Annual banned-substance review: Analytical approaches in human sports drug testing 2019/2020

Analytical chemistry-based research in sports drug testing has been a dynamic endeavor for several decades, with technology-driven innovations continuously contributing to significant improvements in various regards including analytical sensitivity, comprehensiveness of target analytes, differentiation of natural/endogenous substances from structurally identical but synthetically derived compounds, assessment of alternative matrices for doping control purposes, and so forth. The resulting breadth of tools being investigated and developed by anti-doping researchers has allowed to substantially improve anti-doping programs and data interpretation in general. Additionally, these outcomes have been an extremely valuable pledge for routine doping controls during the unprecedented global health crisis that severely affected established sports drug testing strategies. In this edition of the annual banned-substance review, literature on recent developments in anti-doping published between October 2019 and September 2020 is summarized and discussed, particularly focusing on human doping controls and potential applications of new testing strategies to substances and methods of doping specified the World Anti-Doping Agency's 2020 Prohibited List.

Olympic competition climbing: the beginning of a new era-a narrative review

Climbing as a competition sport has become increasingly popular in recent years, particularly the sub-discipline of bouldering. The sport will debut in the Tokyo Summer Olympic Games. National and international competitions have three disciplines: lead (climbing with rope protection), bouldering (climbing at lower heights with mattress floor protection) and speed (maximum speed climbing on a standardised route in 1-on-1 mode). There is also a 'combined mode' of all three disciplines (combined) which forms the Olympic competition format; all competition formats are held on artificial walls. Existing literature describes a predominantly low injury frequency and severity in elite climbing. In comparison to climbing on real rock, artificial climbing walls have recently been associated with higher injury rates. Finger injuries such as tenosynovitis, pulley lesions and growth plate injuries are the most common injuries. As finger injuries are sport-specific, medical supervision of climbing athletes requires specific medical knowledge for diagnosis and treatment. There is so far little evidence on effective injury prevention measures in top athletes, and antidoping measures, in general, requiring further work in this field. An improved data situation regarding high-performance climbing athletes is crucial to ensure that the sport continues to be largely safe and injury-free and to prevent doping cases as extensively as possible.

Dietary Supplement and Food Contaminations and Their Implications for Doping Controls

A narrative review with an overall aim of indicating the current state of knowledge and the relevance concerning food and supplement contamination and/or adulteration with doping agents and the respective implications for sports drug testing is presented. The identification of a doping agent (or its metabolite) in sports drug testing samples constitutes a violation of the anti-doping rules defined by the World Anti-Doping Agency. Reasons for such Adverse Analytical Findings (AAFs) include the intentional misuse of performance-enhancing/banned drugs; however, also the scenario of inadvertent administrations of doping agents was proven in the past, caused by, amongst others, the ingestion of contaminated dietary supplements, drugs, or food. Even though controversial positions concerning the effectiveness of dietary supplements in healthy subjects exist, they are frequently used by athletes, anticipating positive effects on health, recovery, and performance. However, most supplement users are unaware of the fact that the administration of such products can be associated with unforeseeable health risks and AAFs in sports. In particular anabolic androgenic steroids (AAS) and stimulants have been frequently found as undeclared ingredients of dietary supplements, either as a result of cross-contaminations due to substandard manufacturing practices and missing quality controls or an intentional admixture to increase the effectiveness of the preparations. Cross-contaminations were also found to affect therapeutic drug preparations. While the sensitivity of assays employed to test pharmaceuticals for impurities is in accordance with good manufacturing practice guidelines allowing to exclude any physiological effects, minute trace amounts of contaminating compounds can still result in positive doping tests. In addition, food was found to be a potential source of unintentional doping, the most prominent example being meat tainted with the anabolic agent clenbuterol. The athletes’ compliance with anti-doping rules is frequently tested by routine doping controls. Different measures including offers of topical information and education of the athletes as well as the maintenance of databases summarizing low- or high-risk supplements are important cornerstones in preventing unintentional anti-doping rule violations. Further, the collection of additional analytical data has been shown to allow for supporting result management processes.

Prevalence of therapeutic use exemptions at the Olympic Games and association with medals: an analysis of data from 2010 to 2018

Objectives

The percentage of athletes with Therapeutic Use Exemptions (TUEs) competing in elite sport and the association with winning medals has been a matter of speculation in the absence of validated competitor numbers. We used International Olympic Committee (IOC) and World Anti-Doping Agency (WADA) data to identify athletes competing with TUEs at five Olympic Games (Games) and a possible association between having a TUE and winning an Olympic medal.

Methods

We used the IOC’s competition results and WADA’s TUE database to identify the number of TUEs for athlete competitions (ACs, defined as one athlete competing in one event) and any associations with medals among athletes competing in individual competitions. We calculated risk ratios (RR) for the probability of winning a medal among athletes with a TUE compared with that of athletes without a TUE. We also reported adjusted RR (RR_adj) controlling for country resources, which is a potential confounder.

Results

During the Games from 2010 to 2018, there were 20 139 ACs and 2062 medals awarded. Athletes competed with a TUE in 0.9% (181/20 139) of ACs. There were 21/2062 medals won by athletes with a TUE. The RR for winning a medal with a TUE was 1.13 (95% CI: 0.73 to 1.65; p=0.54), and the RR_adj was 1.07 (95% CI: 0.69 to 1.56; p=0.73).

Conclusion

The number of athletes competing with valid TUEs at Games is <1%. Our results suggested that there is no meaningful association between being granted a TUE and the likelihood of winning a medal.