in the athlete
• to better understand the pharmacology of the
most popular molecules.
• know the most common and lethal adverse
reactions associated with their use.
• to determine when ED physicians should
– ask about them
– suspect as potential cause for symptoms
– suggest referral for nutritional counselling.
• Economic market of several billions of USD.
• Expansion in the last 5 years
– Lack of regulation
– Target group vulnerability
• Target group
• Body image
• Peer pressure
• Unrealistic objectives about training
• Ergogenic aid:
any means of enhancing energy utilization including energy
production, control, and efficiency.
– Stimulants; amphetamines, ephedrine, caffeine
– Reduce tremor and HR; Beta blockers
– Bodyweight gain or loss; AAS, GH, B2 agonists,
Strategy is to increase energy consumption, metabolism
while decreasing adipose tissue formation to the benefit of
• Anabolic steroids
• Amino acids
• Chromium picolinate
• Caffeine, ephedrine, Mg, , EPO, GH
• Formed in kidney, liver @ rate of 2 g/day
• Meat and fish
• Typical diet 1-2 g per day
• 95% in muscles (1/3 free Cr, 2/3 PCr)
• Irreversible conversion to creatinine
• Not for aerobic activities
• Acute side effects:
– Gastrointestinal aches
– Muscle cramping ( H2O retention in fibers)
– No long term side effect if therapeutic doses
• Case reports of rhabdomyolysis or
quadriceps compartment syndrome after
• mid 1950’s strenght enhancing properties of
• Minimizing androgenic effect while preserving
• No synthetic molecule dissociating two properties
• Two categories IM vs PO group.
• Androstenedione most popular now.
• DHEA banned by FDA in 1996
– Media attention cause manufacturers to sell it as
nutritional aid rather than therapeutic drug.
– Wild yams sold in health food stores.
• Endogenously produced
• Ergogenic effects
– Unclear rate of conversion to Testosterone when PO
– Studies 300 mg/d users ingests 2-3 times this dose
• Anabolic effects
– Induces protein synthesis
– Binding to cell cytoplasm
– Studies at best weak agents
• Androgenic effects
– Male differenciation in utero
– Maturation of external genitalia
– Secondary sex characteristics
– Regulation sperm production
• Data on side effect in users is minimal.
• Some suggest aromatization to estrogen when PO.
• Unclear if produces the side effect of other AAS
– Hepatic failure
– Hepatocellular carcinoma
– Testicular atrophy
– Because no alpha 1 7 alkylation
– No increase LFT’s
– Sudden death, AMI, cardiac hypertrophy
• Atherogenic model lipoprotein
• Thrombosis model clotting factors
• Vasospasm model vascular nitric oxide system
• Decrease HDL 53%, increase LDL 36%
• Increase fibrosis in myocytes
– Feedback inhibition of LH
– Women and children most at risk
– Growth spurt of adolescence
– Premature epiphyseal plate fusion and short stature
– Predisposition to tendons rupture with local injections
– Abnormal collagen fibers formation (type III)
– Abolish a negative nitrogen balance
– Promoting retention Na, K, Po4
– Decreased urinary excretion of Ca
– Agressivity, mood swings, cognitive impairments
• Few sides effects reporte
• Irreversible virilization of women, hirsutism, voice
deepening, hair loss
• Irreversible gynecomastia
• Increase risk of uterine and prostate cancer that
accompagnies unopposed elevation in testosterone
• Systemic B2 agonist (stimulant)
• Reduce fatigue, sensitivity to pain,
• Increase alertness, reaction time,
• Promotes muscle growth
• Large reduction in body fat
• Stimulate protein deposition in muscles by
• Reduces glycogen and body fat deposition
• Skeletal muscles:
– Increases glycolytic capacity
– Induces a true hypertrophy vs hyperplasia
– Shift fiber type I (slow twitch) to II (fast)
• Approved in Europe, Canada for livestock.
• Most symtoms are tachycardia, tremors,
headaches, dizziness, nausea, fever.
• Case report of ventricular arrhythmias but
patient also undergoing hypocaloric diet.
• The protein shake
• Daily requirement 0.8g/kg/d
• Some benefit from extra 0,5g/kg/d
• Beta hydroxy beta methyl butyrate
• No studies have shown any benefit
• No major side effect
• No well designed studies either
• Popular in USA as liquid X
• Release GH and burn fat during periods of
inactivity, such as sleep.
• Investigated to treat EtOH WD in Europe
• Use is illicit
• Potentiates dopamine R in brain and GABA R
• Side effects:
– related to decrease LOC
– absences types seizures.
• OD setting:
– Respiratory depression
– Exacerbation with Et-OH
– No response with naloxone
– Flumazenil in animals studies
• Essential trace element
• Low GI absorption
• Popularity after found increase chromium loss
• Claims it increases glycogen synthesis
• Enhances action of insulin
• Increase incorporation of AA in muscles
• Major side effects
• Use should be discouraged
• Part of many “combo products”
• Anabolic steroid effect at dose of 200ug/day
• Anecdotal report of anemia, cognitive impairment
• Interstitial nephritis.
• Gastritis and GI intolerance if
– > 200 ug/d
– more than one month “ treatment”
Route of administration
• SC for EPO
• Needle sharing
– Across users
– Across times
• Different brands
• Differents dosages
• Purity issues
• Combinations within same product
• Users are adolescent
• Increased risk of engaging in other drug use
– IV drug use
• Gastrointestinal symptoms
• MSK: tendinitis, myalgias
• Renal failure
• Chest pain
• Yearly “medicals” in sports clinics.
Parallel with Viagra, nitrates and chest pain
• Likely increase in incidence.
• Easy to get, unregulated
• Mosty long term adverse effects
• Symptoms that are frequent chief complaints
in our ED.
• We might not know unless we ask
• Fragile, “uneducated”, unsupervised clientele.