Applied Evidence

Performance-enhancing drugs snare nonathletes, too

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High school athletes aren’t the only ones seeking an edge. Here are the red flags and unexpected drugs to watch for



Practice recommendations
  • Multiple adverse effects, including serious cardiovascular effects, have prompted bans on the sale of anabolic androgenic steroids (AAS) and their use in competition (A).
  • Most users of AAS and other performance-enhancing drugs are nonathletes or recreational body builders who begin using these substances in their teen years. Ask about steroid or supplement use during yearly physicals (C).

Strength of recommendation (SOR)

  1. Good-quality patient-oriented evidence
  2. Inconsistent or limited-quality patient-oriented evidence
  3. Consensus, usual practice, opinion, disease-oriented evidence, case series

JC, a 23-year-old man, is in your office for evaluation of high blood pressure, after failing a commercial driver’s license exam the previous week. He has been your patient for the past 10 years, and his previous annual physicals have been unremarkable. He is 5’10’’ tall, weighs 209 pounds, and has a muscular build. His blood pressure today is 160/90 and his heart rate is 62 and regular. The rest of his physical exam is normal.

He is a nonsmoker, rarely uses alcohol, and denies illicit drug use. He exercises regularly, has been taking some protein shakes and what he refers to as a “natural” supplement. His lab work shows some elevation in his aspartate aminotransferase (AST) and alanine aminotransferase (ALT), with a negative hepatitis panel. The rest of his metabolic panel is within normal limits.

JC was on the track team in high school, and since graduation has continued to work out and stay fit. You ask him if he takes steroids, and he tells you he was warned about the risks of anabolic androgenic steroids (AAS) in high school. He sticks to a “natural” supplement, which he buys online or through friends at the gym. Still, you know that elevated liver enzymes and hypertension can be associated with AAS use and that dietary supplements don’t have to meet the same standards the Food and Drug Administration (FDA) imposes on drugs. (See “What’s in that supplement? Labels don’t always help” on page 18.) You warn him that supplements aren’t always safe, and ask him to bring in his supplement bottle so you can go over the label and, possibly, have the contents tested.

Pursuit of that “edge” extends beyond Olympians

Even before the start of the modern Olympic games, athletes have used ergogenic aids—substances used to enhance performance, energy, or work capacity—to give themselves a “competitive edge.”1,2 Athletes still use these substances today, and they have been joined by nonathletes—some of whom simply want to look good.

A 2004 Internet study of AAS users reported that the majority are recreational bodybuilders or nonathletes. Twenty-five percent of participants in this survey reported starting using steroids during their teenage years.3

An ongoing study of high school students and young adults indicates an AAS use prevalence rate of 1.1% to 2.3% in boys and 0.4% to 0.6% in girls. Approximately 40% of survey participants noted that obtaining steroids was relatively easy.4

The Centers for Disease Control and Prevention (CDC) reports that 4.4% to 5.7% of boys (grades 9 through 12) have used illegal steroids and that 1.9% to 3.8% of girls have.5

Few AAS users tell their physicians of their steroid use. Part of the reason, of course, is that illegal substance use is stigmatized and can lead to prosecution. Another reason, though, is that these patients think physicians don’t know much about these substances.3 Still other patients, like JC, don’t tell because they may not even be aware that some substances billed as “natural” conceal potential dangers.

For help in spotting patients who are using these agents, see “Red flags for performance-enhancing drug use” on page 20.

Performance-enhancing drugs go by many names

Refining your care of patients who are taking performance-enhancing drugs requires that you know the various names these drugs go by, the reason your patients may be taking them, and the adverse effects associated with them. This review, and the TABLE, will help.

Performance-enhancing agents: What to watch for

Anabolic androgenic steroids (AAS)
  • Increase lean muscle mass at supraphysiologic doses
  • Increase protein synthesis
  • Stimulate production of growth hormone
  • Decrease perception of fatigue
Acne, gynecomastia,* testicular atrophy,* virilization in females,* premature physeal closure, elevated liver enzymes, increased aggression, hypertension, CAD, sudden death
  • Polypharmacy with other ergogenic agents and anti-estrogens is common
  • Possession and use are against the law, and athletes found to be using AAS are banned in competition by sports authorities
Tetrahydrogestrinone (THG)Data on ergogenic use are insufficientHepatotoxicity; side effect profile probably similar to AAS
  • Evidence on effectiveness and side effects is insufficient
  • Use is illegal
Androstenedione (Andro)Increase testosterone levels in order to build muscleIncreased estradiol levels, feminization, priapism; side effect profile probably similar to AAS
  • Conflicting evidence on how drug affects testosterone levels
  • Banned in competition by sports authorities
Dehydroepiandrosterone (DHEA)Increase testosterone levels for anabolic effectsIncreased estrogen and estradiol levels, virilization, increased risk of endometrial cancer in females
  • Insufficient evidence to support claims as an anabolic or anti-aging agent
  • Sold as a supplement but banned for use in competition
Human growth hormone (HGH)Increase protein synthesis and muscle mass without unwanted androgenic effects, decrease body fatInsulin resistance, premature physeal closure, acromegaly, hypertension, cardiomegaly
  • Insufficient evidence that use enhances athletic performance
  • Expensive
  • Usually used in addition to AAS
  • Banned for use in competition
EphedrineWeight loss, increase energy, increase concentrationAnxiety, panic attacks, hypertension, tachycardia, MI, strokeBanned by the FDA because of cardiovascular and stroke risk
CaffeineIncrease alertness and energy, weight loss, improve enduranceAgitation; potential for withdrawal symptoms; hypertension, arrhythmia, and stroke when used with ephedrine or other stimulantsUrinary threshold in NCAA and Olympic competition
Erythropoietin (EPO)Increase oxygen-carrying capacity of blood in endurance athletesPulmonary embolism, MI, stroke, development of anti-EPO antibodiesBanned in all sports competition
CreatineIncrease production of ATP in skeletal muscle during anaerobic exerciseMuscle cramps, weight gain, minor gastrointestinal upset
  • No long-term studies available
  • Not recommended in minors
  • Legally sold as a dietary supplement
SildenafilVasodilation, increase oxygenation and exercise capacityHeadache, flushing, dyspepsia, blurring of visionNo action yet to ban in athletic competition
ATP, adenosine triphosphate; CAD, coronary artery disease; FDA, Food and Drug Administration; MI, myocardial infarction; NCAA, National Collegiate Athletic Association.
* These adverse effects may be irreversible.


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