Where are the boundaries Robert Palinkas MD I have NO actual or potential conflict of interest in relation to this educational activity or presentation Most of the agents I discuss have very limited ID: 914579
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Slide1
Medical Aspects of Performance Enhancing Agents
Where are the boundaries?
Robert Palinkas, M.D.
Slide2I have NO actual or potential conflict of interest in relation to this educational activity or presentation
Most of the agents I discuss have very limited
FDA approved use, and all off label use of any agent in this talk is strongly discouraged
But First
Slide3Land of the Fighting Illini
Greetings from Illinois
Slide4Substances used by athletes to improve their performanceSometimes also used by military personnel to enhance combat performance
A broad group of agents
Steroids (“roids
”) are just one type of PED
Not all PED’s are illegal
What are
performing enhancing agents (PED’s)?
Slide5Lean Mass buildersStimulantsPainkillers
Sedatives
DiureticsBlood boostersMasking drugs
The categories of PED’s
Slide6Amplify muscle growth and/or reduce reduce fat deposition
Anabolic steroids
Androgens and Xenoandrogens
Human growth hormone
HCG
Antiestrogens
The Lean Mass Builders
Slide7CaffieneAmphetamine
Methamphetamine
Beta agonists
The Stimulants
Slide8Beta blockers
Sedating enhancers
Slide9Epogen (EPO)
Blood Boosters
Slide10Probenecidepitestosterone
Masking agents
Slide11Who uses performance enhancing agents?
Slide12Alex Rodriguez- Highest paid NY Yankee
Slide13Lance Armstrong- Winner of Several Tours de France?
Slide14Arnold
Schwarzenneger
- Former Governor of California
Slide15From T-Nation
Slide16From National Institute on Drug Abuse
Slide17To improve competitive positionFor example, body building
To look better
For example, easier weight lossTo “feel” betterFor example, recapture libido from an earlier age
Because of a distorted self image
As in the eating disorders
Because of a mental condition
As part of obsessive compulsive disorder
Because of financially driven providers
Big pharma and entrepreneurial
doctors
Why do people use performance
enhancing agents
Slide18Testosterone synthesized and changed 19351952 First use of anabolic steroids at the Olympics1976 IOC bans
anabolics
1986 IOC begins testing for substancesWADA established- the World Anti Doping Agency
When did this trend begin?
Slide19Most useExercise
Diet manipulation
Various supplementsMany can be obtained at your local nutrition store
Some use
Testosterone or pre-testosterone
Usually cycled
Anabolic steroids
Usually cycled
Antiestrogens
To prevent
gynecomastia
-SERMs and aromatase inhibitors
HGH or HCG
To decrease fat and preserve testicular size
What is the typical bodybuilder using?
Slide20Exercise is essentialThere is no way to build muscle without physical trainingNutrition is essential
Need the substrates for new mass and replacement through
catabolismWhen both are in the right place, hormonal influences
can make a big difference
Building Muscle
Slide21Natural Body Building
Slide22Phil Heath Winner
Mr
Olympia 2012
Slide23Once Again
Slide24Natural Body Building
Slide25Phil Heath Winner
Mr
Olympia 2012 No testing done here
Slide26Many patients devise their own hormone regimen or use a regimen someone recommended for them
The recommender may be unlicensed
Most will use some form of anabolic steroidMany will manipulate their testosterone
Some
will add HGH
Some will use an
antiestrogen
agent like aromatase inhibitors
The process involves alternating or varying doses in a cycle or “stack”
Combined with variation in diet and exercise
The Hormone Sandbox
Slide27The Big Dog
Slide28Slide29Steroids start with a sterol
A generic sterol
Cholesterol
Slide30Important organic moleculesPresent in both plants, animals and fungiVery versatile
Used in cell membranes and as secondary messengers
The Sterols
Slide31Slide32AndrogensAndrogenic effectssecondary sex characteristics
Anabolic effects
Growth of muscle mass and strength
Increased bone density
Male Hormones
Slide33Testosterone
Slide34Slide35Continuous or frequent use is likely to result in testicular atrophy and may result in infertility
Testosterone Use
Slide36The path to testosterone and beyond
Slide37Slide38Have both an androgenic effect and an anabolic effectSome are significantly stronger at stimulating muscle growth, lipolysis
The Anabolic Steroids
Slide39The Common Anabolic Steroids
Slide40Structures of the Common Anabolic Steroids
Slide41US pharmaceutical manufacturersRarelyManufacturers outside the US
A significant portion
Some are from decent manufacturersUnlicensed
US and foreign chemists
The majority
Where
do the agents come from?
Slide42Slide43Slide44Slide45Slide46Slide47Some are legal over the counter agents“supplements” exempt from FDA oversight
New agents,
prehormonesSome are just plain smuggled into the country
Some are purchased on the internet
Some are distributed by word of mouth in the sports community
Some are derived from unlicensed “medical” operations
Some are prescribed by licensed providers incented by profit and sympathy
How do patients get access to HGH, androgens,
anabolics
?
Slide48Mostly Anabolic SteroidRaw ingredients easily obtained
Don’t meet FDA standards
High Profit
The Underground Labs
Slide49I had no difficulty buying 63 pounds of raw material on the internetSale was not completed
Start with raw material-testosterone
Slide50Set up a basic
chem
lab
Slide51Try to keep it clean
Slide52Package the end product
Slide53Slide54The Pituitary Approach
Slide55HCGStrong lipolysisUsed for weight loss
Some protection from testicular
arophy
HGH
Supports lipolysis
Strong muscle growth
Protects against testicular atrophy
The Pituitary Approach
Slide56Too numerous to list
Creatine
Not so badNot so effectiveNO
BCAA
Safety Is a huge concern
FDA: 70% of industry violate rules
About half are way off on potency
20% contain contaminants
3000 products recalled 2012
6000 complaints filed in 4 years
The Supplements
Slide57Focus on insecuritiesAging Waning sexual function
Waning strength
Weight gainCan be lucrativeAt least a 28 Billion dollar industry on supplements alone
The business side
Slide58A Testosterone Ad
Slide59Slide60Slide61Slide62Slide63An anti-aging ad
Slide64A anabolic steroid ad
Slide65An HGH Ad
Slide66Ad From
Antiagenyc
for hgh
Slide67hGh
- enhances growth, reduces fat deposition
Slide68Those that are illegalThose that are dangerousThose that come from questionable sources
Possible contamination
Those that are injectedThose that are outside the medical orthodoxy
What are the agents of concern?
Slide69The most powerful agents are injected
Slide70TestosteroneHGH
Synthol
A host of anabolic steroids
The menu of
injectables
Slide71Also called synthrol
An injectable viscous liquid
Used cosmetically to increase muscle sizeContains an oil,
lidocaine
and sometimes alcohols
Synthol
Slide72A
synthol
user
Slide73Slide74Synthol
Muscle Injury
Slide75An evolving processReluctance to impact the financial consequences
Reluctance to draw attention or tarnish the sport
New chemicals need new tests Depends on the sportAvailable resources for testing
Strength of the regulatory agency
Prevalence of use in the sport
Sports Regulation
Slide76Requests for frequent testosterone assaysClaims about low testosterone but discordant clinical features
Youth
Normal appearing testesMuscular habitus
Absence of neurologic-hypothalamic
clues
Evidence of doctor shopping or different views
Insistence
Long lists of associated tests
Estradiol
Estriol
Progesterone
DHEA
hGH
Prolactin
Sex
hormone binding globulin
Clues- in
males
Slide77Out of our scope of practiceWe follow the orthodoxyNot alternative medicine
Need for fiscal
stewardshipDraws McKinley staff into
medicolegal
involvement
Our action:
lab restriction on estradiol testing in
men and frequent testosterone assays
Why McKinley at U of I Doesn’t Assist
Slide78Some of this is a difference of philosophyMaybe we should all help patients use medications to resist aging or for
cosmesis
Or moralsWho are we to judge the way people wish to look
But for now
There is no universally accepted treatment regimen approved for this application
In the end