Andy Peterson MD MSPH

University of Iowa

HEALTH SUPERVISION OF THE DOPING ATHLETE

DISCLOSURES

• Grants:

• UI Injury Prevention Research Center

• NIH sub-contract

• B1G conference

• American Academy of Pediatrics

• Royalties from McGraw-Hill

• Intellectual property with Team Safesport

• Wife (Vanessa Curtis) receives consulting fees from Rhythm Pharmaceuticals

GOALS AND OBJECTIVES

1. Ethical Basis of Caring for Doping Athletes

2. Monitoring of Common Drugs (mainly anabolics)

3. Pitfalls and Red Flags

A FEW KEY ADDITIONAL POINTS

• There is almost no data to guide us here

• Don’t break the law

• No one up here is advocating for use of

PEDs in sports

• All of the example cases are real

PRINCIPLES OF MEDICAL ETHICS

1.Principle of respect for autonomy

2.Principle of nonmaleficence

3.Principle of beneficence

4.Principle of justice

Beauchamp and Childress (2008)

DON’T LIE TO PATIENTS

HOW DO PEOPLE TAKE THEM?

• Injectable

• Oral

• Topical

• Single

• Stacked

• Pyramid

• Cycled

CASE 1

28 year old male graduate student

Recreational weight lifter – body image / appearance

Creatine (oral)

Dianabol (metandienone) (oral)

Anadrol (oxymetholone) (oral)

Testosterone (injection)

Trenbolone (injection)

Levothyroxine (oral)

Methylphenidate (oral)

CASE 1 – MORE INFORMATION

Interested in ”backing off”

Has noticed elevated BP when checked at pharmacy (150s systolic)

Concerned about acne

No other side effects noted

Tried to quit once before – went very poorly

CASE 1 – EXAM

Pertinent abnormal findings:

BP 142/74

Highly virilized

Diffuse acne

Severe folliculitis from body hair grooming

Testes 2cm and firm

Pertinent normal findings:

Normal heart exam

No hepatosplenomegaly

Normal affect

• WBC 5.9; nl diff

• Hgb 19, Hct 58

• Plt 222

• Total Testosterone 994

• FSH 0.1

• LH < 0.1

• TSH 0

• Total Cholesterol 134

• HDL 12

• TG 155

• LDL 91

• Normal:

• Liver tests

• ECG

• Echo

• Electrolytes

CASE 1 – LABS

• WBC 5.9; nl diff

• Hgb 19, Hct 58

• Plt 222

• Total Testosterone 994

• FSH 0.1

• LH < 0.1

• TSH 0

• Total Cholesterol 134

• HDL 12

• TG 155

• LDL 91

• Elevated BP

Creatine (oral)

Dianabol (metandienone) (oral)

Anadrol (oxymetholone) (oral)

Testosterone (injection)

Trenbolone (injection)

Levothyroxine (oral)

Methylphenidate (oral)

CASE 1 – REVISIT PEDS

PLAN

• Continue Creatine, Methylphenidate

• Stop all anabolics except Testosterone

• Wean off synthroid over 4 weeks

RESULT (6 WEEKS)

• BP 122/68

• NL CBC

• TSH 1.1

• HDL 10

• Total Test 990

• Not interested in stopping

CASE 1 -- PLAN

ORAL ANABOLICS

ORAL ANABOLICS

ORAL ANABOLICS

17-ALPHA-ALKYLATED STEROIDS

1. By far most commonly used oral anabolics

2. More anabolic effect = more hepatotoxicity

3. 3 categories:

• Testosterone based (high estrogen effect)

• DHT based

• Nandrolone based

Dianabol (metandienone) (oral)

• Testosterone derivative

• Highly hepatotoxic

Anadrol (oxymetholone) (oral)

• DHT derivative

• Weak anabolic

• Weakly hepatotoxic

• Previously used clinically to treat

anemia

A FEW EXAMPLES – WHAT OUR PATIENT WAS ON

Stanozolol

• DHT derivative

• Highly anabolic

• Highly hepatotoxic

Oxandrolone

• DHT derivative

• Weak anabolic

• Weakly hepatotoxic

A FEW EXAMPLES – MOST COMMON

CASE 2 (EMAIL FROM HOSP EXECUTIVE RE HIS SON)

I’ve been through three cycles, first starting with the following: 250 mg/ml Trenboloneethanoate, 250mg/ ml Testosterone ethanoate and 1mg of Arimidex oral tablets. The second and third cycle consisted of 100mg/ml Trenbolone Acetate (stronger concentration), 250mg/ml Testosterone ethanoate, 1mg Arimidex and for the last two weeks of the cycle lasting for an additional four more weeks 25mg Winstrol oral tablets.

For proximal results, a 10-week cycle is recommended. Although, I did not want to endure high dosages of these supplements. My cycle originally consisted of 1ml total between trenand test, then a half tablet of Arimidex every two days. The dosage of test was then depreciated to .2ml (~1/2) its original dose for the reason that I started to retain water. During my second cycle, I did 1.2ml of tren acetate and test combined—1ml of tren and .2ml of test. The dose of Arimidex remained the same, as for Winstrol, a half of a tablet was orally consumed (the last two weeks continuing for four additional weeks) every day. The process was first to obtain the oily substance (Trenbolone) then testosterone. Reason I did it this way was because the oil would sit at the back of the syringe and you’d notice the separation between liquids.

CASE 2 (EMAIL FROM HOSP EXECUTIVE RE HIS SON)

I’ve been through three cycles, first starting with the following: 250 mg/ml Trenboloneethanoate, 250mg/ ml Testosterone ethanoate and 1mg of Arimidex oral tablets. The second and third cycle consisted of 100mg/ml Trenbolone Acetate (stronger concentration), 250mg/ml Testosterone ethanoate, 1mg Arimidex and for the last two weeks of the cycle lasting for an additional four more weeks 25mg Winstrol oral tablets.

For proximal results, a 10-week cycle is recommended. Although, I did not want to endure high dosages of these supplements. My cycle originally consisted of 1ml total between trenand test, then a half tablet of Arimidex every two days. The dosage of test was then depreciated to .2ml (~1/2) its original dose for the reason that I started to retain water. During my second cycle, I did 1.2ml of tren acetate and test combined—1ml of tren and .2ml of test. The dose of Arimidex remained the same, as for Winstrol, a half of a tablet was orally consumed (the last two weeks continuing for four additional weeks) every day. The process was first to obtain the oily substance (Trenbolone) then testosterone. Reason I did it this way was because the oil would sit at the back of the syringe and you’d notice the separation between liquids.

“DO YOU BELIEVE WHAT HE IS DOING IS SAFE?”

GENERAL RESPONSE

1. This is illegal

2. A lot of the sources where people get it aren’t reliable, so strength and purity are often

questionable

3. Long-term, there are real effects on cardiovascular health.

• But, over the short to medium-term, not super high risk.

SPECIFIC RESPONSE

• The trenbolone and testosterone are both strong anabolics that are commonly taken together. There is some risk of withdrawl if he comes off quickly.

• Tren metabolites are highly aromatized, so the arimidex he takes when on that should limit some of the edema and estrogen-like side effects.

• Biggest risk is probably from the Winstrol (which is stanozolol, probably the most commonly abused anabolic steroid). It is a 17-alpha-methylated steroid, which is why it can be taken orally, but also increases risk of liver injury. And, big-picture, it is a pretty weak anabolic. So, with the doses he is taking of Test and Tren, it is unlikely to be adding much other than increased risk.

• If he were my patient, I would probably counsel him on 1,2,3 above, check his heart, liver, RBC count, and lipid panel. And encourage him to stop the stanozolol.

MONITOR ANABOLICS

• Thyroid: Thyroid levels-Decreased TBG, decreased T4

• Liver: INR-increased, Other liver tests-Neoplasms, Peliosis hepatitis (blood filled cysts)

• CNS: Depression, excitation, insomnia

• GI: Nausea, vomiting, diarrhea

• Breast: Gynecomastia

• Larynx: Voice deepening

• Hair: Hirsutism and male pattern baldness

• Skin: Acne

• Skeletal: Premature closure of epiphysis in children

• Fluid and Electrolytes: Edema, fluid retention-Na, Cl, K, Phos, Ca

• Metabolic/Endocrine: Decrease glucose tolerance, Increased LDL, decreased HDL, Elevated creatinine, Increased CK, insulin levels for exogenous use

• Heart: Monitor HTN, cholesterol

• GU: Prostate enlargement, prostate CA, bladder irritability

• Heme: CBC for polycythemia

• Oral steroids are more hepatotoxic

• Higher doses have more side effects

• Hypertension

• Polycythemia

• Suppress HPG axis

• Androgen effects

• Including mood / aggression?

MONITOR ANABOLICS (BRIEF TAKE HOME)

• Encourage transition to testosterone

• If HPG axis suppressed, plan 30-90

day taper

• Consider clomiphene

• ??LH/FSH recovery??

• Consider psychologist

• Consider ED meds.

If oral 17-alpha-alkylated testosterone

• Consider Tamoxifen

• ??LH/FSH recovery??

• Decrease peripheral estrogen

effects??

WEANING ANABOLICS

• Fitness competitor

• 2014:

• Synthroid 100µg/d

• Caffeine 800mg pre workout

• DHEA

• Testosterone (patch)

• Rare palpitations

CASE 3

Edema (30 lbs)

Sleep disturbance

Hair loss

Brittle nails

Dry skin

1 month after competition

• TSH: 0.1 (L)

• Free T4: 0.15 (L)

• Reverse T3: 3 (L)

• TBG: 22 (NL)

Normal

• LH, FSH, Estradiol

• CMP

• Cholesterol Panel

• ECG

CASE 3 – AFTERMATH

Rubinoff and Fireman. J Clin Epidemiol. 1989.

Vagenakis. NEJM. 1975.

• Restart synthroid 25µg/d

• Dx: central hypothyroidism

• 1 month follow up

• Felt normal

• Weight still up

• Started wean over next 8 weeks

• 3 month follow up

• Felt normal

• Weight back to normal

1 month

• TSH: 0.2

• Free T4: 6.22

3 month

• TSH 0.26

• Free T4: 4.15

CASE 3 – PLAN

CASE 3 – 2 YEARS LATER

Returned to competition

• Testosterone patch

• Creatine

• Caffeine

• No side effects

• Normal labs

• Weaned off quickly after competition

Monitoring

• TSH, FT4

• Vital signs

• Cardiac testing to symptoms

• Palpitations

• Fatigue

• Exercise intolerance

Weaning off

• Should be quick and easy

• Lots of anecdotes of long recovery

• No real down-side to weaning dose

THYROID HORMONE

Most common

• Caffeine

• Methylphenidate

• Amphetamine salts

• Benzadrine

• Nicotine

• Clenbuterol (also anabolic)

Side effects

• Cardiovascular

• Sleep

• Mental Health

• Increased heat illness risk

• Tremor

• Sexual dysfunction

STIMULANTS

Monitoring

• ??ECG??

• Counseling re titration and heat illness

Weaning off

• Nothing to do.

STIMULANTS

Monitoring: None Weaning: Non Issue

CASE 4

• 26 yo elite MTB racer

• History of anemia in college – treated with IV iron

• Started using EPO to “prevent anemia”

• Now

• Caffeine

• EPO: 3000 IU / week

”Can you refill it for me?”

• Counseled regarding legal / ethics

• Discussed risk of polycythemia

• Ensured no other polypharmacy issues

NL CBC, iron, TIBC, ferritin, transferrin

Planed to recheck every 6 months or after

change in dose → never saw him again.

CASE 4

Monitoring: No one knows

“case reports”

Weaning: Nothing to do

EPO: MONITORING / WEANING

TAKE HOME POINTS

• Take care of the patient

• Don’t break the law or violate medical ethics standards

• Know the drugs