- 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)
- Good-quality patient-oriented evidence
- Inconsistent or limited-quality patient-oriented evidence
- 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
|DRUG/SUPPLEMENT||ERGOGENIC USE||ADVERSE EFFECTS||COMMENTS|
|Anabolic androgenic steroids (AAS)||Acne, gynecomastia,* testicular atrophy,* virilization in females,* premature physeal closure, elevated liver enzymes, increased aggression, hypertension, CAD, sudden death|
|Tetrahydrogestrinone (THG)||Data on ergogenic use are insufficient||Hepatotoxicity; side effect profile probably similar to AAS|
|Androstenedione (Andro)||Increase testosterone levels in order to build muscle||Increased estradiol levels, feminization, priapism; side effect profile probably similar to AAS|
|Dehydroepiandrosterone (DHEA)||Increase testosterone levels for anabolic effects||Increased estrogen and estradiol levels, virilization, increased risk of endometrial cancer in females|
|Human growth hormone (HGH)||Increase protein synthesis and muscle mass without unwanted androgenic effects, decrease body fat||Insulin resistance, premature physeal closure, acromegaly, hypertension, cardiomegaly|
|Ephedrine||Weight loss, increase energy, increase concentration||Anxiety, panic attacks, hypertension, tachycardia, MI, stroke||Banned by the FDA because of cardiovascular and stroke risk|
|Caffeine||Increase alertness and energy, weight loss, improve endurance||Agitation; potential for withdrawal symptoms; hypertension, arrhythmia, and stroke when used with ephedrine or other stimulants||Urinary threshold in NCAA and Olympic competition|
|Erythropoietin (EPO)||Increase oxygen-carrying capacity of blood in endurance athletes||Pulmonary embolism, MI, stroke, development of anti-EPO antibodies||Banned in all sports competition|
|Creatine||Increase production of ATP in skeletal muscle during anaerobic exercise||Muscle cramps, weight gain, minor gastrointestinal upset|
|Sildenafil||Vasodilation, increase oxygenation and exercise capacity||Headache, flushing, dyspepsia, blurring of vision||No 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.|