Performance-enhancing drugs snare nonathletes, too

Adverse effects of EPO use are attributed to increased blood viscosity and thrombotic potential. Pulmonary embolism, stroke, myocardial infarction, and sudden death can occur.¹⁹ Cases of death due to severe bradycardia, usually occurring during the night, have also been reported.²³ Development of anti-EPO antibodies may also occur, causing paradoxical anemia.²³ Athletes found to be using rEPO are banned from competition by sports-governing organizations.

Creatine: Popular among body builders

Creatine is a popular supplement used by athletes and recreational bodybuilders to provide energy to skeletal muscles in short-duration, maximal exercise.⁴⁴ It is an endogenous substance found mainly in skeletal muscle and is synthesized by the liver from the amino acids glycine, arginine, and methionine.^11,44 It is also found in meat.

Creatine monohydrate supplements have been found to increase creatine stores in muscles.⁴⁵ In the phosphorylated form, creatine serves as a substrate for adenosine triphosphate resynthesis during intense anaerobic exercise.^11,44-46 Numerous studies support its ergogenic effect on short-term, intermittent maximal activities such as bodybuilding, swimming, and jumping. Similar benefits have not been proven for endurance aerobic activities, such as long-distance cycling or running.^46,47

This supplement is sold in many forms under such names as Rejuvinix, Cell Tech Hardcore, Muscle Marketing, Femme Advantage, and NOZ. Although not recommended for those under age 18, creatine is actually used by approximately 5.6% of high school athletes, with the highest levels of use (44%) occurring in the 11th and 12th grades.⁴⁸ Reported side effects of creatine include muscle cramps, weight gain, and some minor gastrointestinal upset. Long-term studies on creatine supplementation are still needed.

Viagra (that’s right, Viagra)

Viagra (sildenafil) is the latest entry in the list of drugs competitive athletes may be using to try to improve sports performance. The World Anti-Doping Agency is financing a study investigating whether sildenafil can create an unfair competitive advantage by dilating blood vessels and increasing oxygen-carrying capacity.⁴⁹ Studies of the impact of sildenafil on exercise capacity of climbers at the Mt. Everest base camp and on exercise performance during acute hypoxia have been published.^50,51 Sildenafil was found to improve athletic capacity in both. To date, no action has been taken to ban the substance in athletic competition.

Are your patients using these agents? Ask them

Family physicians need to be alert to the red flags that may indicate steroid use and gently explore the full list of medications, over-the-counter products, and dietary supplements patients may be using. Take advantage of annual checkups and sports physicals to ask about use of performance-enhancing substances, educate patients on the risks involved, and emphasize good nutrition and sensible exercise routines as healthy ways to build a strong, attractive physique.

Education was certainly in order for your patient, JC, described at the beginning of this article. He thought the dietary supplement he used was natural and therefore harmless. Not so. It contained potentially dangerous substances, so you advised him to stop using it. Nutritional counseling and a vigorous exercise routine have allowed JC to maintain his fitness ideal. His blood pressure and liver enzymes returned to normal levels, and he passed his commercial driver’s license exam.

Correspondence
Marifel Mitzi F. Fernandez, MD, 600 Woodside Drive, Cornell, WI 54732; mffernandezmd@gmail.com