Steroids & Stimulants

Author: Anay Patel

Topic updated on 01/30/13 10:09pm

Anabolic steroids

Introduction
- cause increase in muscle strength
- increase aggressive behavior
- increased erythropoiesis
- side effects
  - hypertension
  - liver tumors
  - increased LDL
  - decreased HDL
  - hypercholesterolemia
Intake
- either oral or injection routes possible
Evaluation
- an abnormally low high-density lipoprotein level should alert the physician to the possibility of steroid use in an athlete.
- blood testing examines for testosterone to epitestosterone ratio of > 6:1
Physical exam
- increased body weight
- testicular atrophy
- irreversible deepening of female voice
- alopecia (irreversible)
- reduction in gonadotropic and sex hormones (estrogen and testosterone)
  - can lead to decreased bone mineral density
  - oligospermia or azoospermia
- growth retardation
- gynecomastia
Type of steroids
- Human Growth hormone (HGH)
  - the most abundant substance produced by the pituitary gland. Growth hormone has a direct anabolic effect by accelerating the incorporation of amino acids into proteins. It is becoming an increasingly popular anabolic steroid substitute;
  - similar effects from insulin-like growth factor (IGF-1)
  - increased muscle size but not strength
  - Side effects:
    - myopathic muscles development
    - carpal tunnel syndrome
    - insulin resistance
- Androstenedione
  - an androgen produced by the adrenal glands and gonads
  - acts as a potent anabolic steroid and is converted in the liver directly to testosterone with a resultant increase in levels after administration.
- DHEA
  - is a naturally occurring hormone made by the adrenal cortex.
  - it is converted to androstenedione, which in turn is converted to testosterone.
  - the beneficial and adverse effects of DHEA can be correlated directly with those of testosterone.
- Erythropoietin (EPO)
  - stimulates hemoglobin production and increases O2 carrying capacity
  - side effects
    - increased blood viscosity which can lead to stroke or myocardial infarctions
- Somatotropin
  - a growth hormone that causes hypertrophy of type 1 muscles and atrophy of type 2 muscle

Catabolic Hormones

Glucagon
- has a catabolic effect on skeletal muscle

Supplements

Creatine
- Introduction
  - derived from glycine, arginine, and methionine
  - a muscle and power building supplement (not an anabolic steroid)
  - mechanism is that creatinine is converted to phosphocreatine, which acts as a source of ATP for muscle
    - studies have shown although it can increase work in anaerobic trials, it cannot increase peak force
  - widely used in conjunction with off-season weight lifting programs
- Outcomes
  - studies show mixed results with regard to enhanced sports performance
- Risks
  - pulls water from blood vessels into cells, creating a theoretical risk of dehydration
- Reports of
  - cramps
  - increased muscle injury
  - renal insufficiency (rare)

Stimulants

Includes
- caffeine
  - doses of 2 to 3 mg/kg have been shown to improve performance
  - works by reducing fatigue and increasing alertness
  - banned by the International Olympic Committee (IOC)
- ephedra
- ephedrine
- "ma huang"
  - often included in energy drink
- amphetamines
Risks include
- dehydration
- impaired heat management
- high blood pressure
- nervous system impairment

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Qbank (5 Questions)

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(SBQ07.19) Which of the following is a side-effect from anabolic steroid use? Topic

Review Topic

1. Liver damage
2. Decrease in low density lipoprotein
3. Decreased blood pressure
4. Decrease in fat
5. Decrease in high density lipoprotein

PREFERRED RESPONSE ▶

DISCUSSION: Anabolic steroids decrease high-density lipoprotein levels. They may either increase or have not effect on low-density lipoprotein levels and are not proven to cause liver damage. Elevations in blood pressure have been observed in athletes who use anabolic steroids. They do not appear to decrease fat mass. Abnormally low high density lipoprotein levels may suggest steroid use in an athlete.

Hartgens et al along with Blue et al showed that steroid use led to decreases in HDL in bodybuilders.

Hartgens and Kuipers outline in a review article the effects of anabolic steroids including its effect on the immune, endocrine, and cardiovascular system.

In the recent review by Achar et al, the effect of steroids on the cardiovascular system are discussed especially in regards to the education of athletes and their evaluations by physicians.

REFERENCES:

1. Hartgens F, Rietjens G, Keizer HA, Kuipers H, Wolffenbuttel BH. Effects of androgenic-anabolic steroids on apolipoproteins and lipoprotein (a). Br J Sports Med 2004;38:253-259. PMID:15155420 (Link to Abstract)

2. Blue JG, Lombardo JA: Steroids and steroid-like compounds. Clin Sports Med 1999;18:667-689. PMID:10410848 (Link to Abstract)

3. Hartgens F, Kuipers H: Effects of androgenic-anabolic steroids in athletes. Sports Med. 2004;34(8):513-54 PMID:15248788 (Link to Abstract)

4. Achar S, Rostamian A, Narayan SM. Am J Cardiol. 2010 Sep 15;106(6):893-901. Cardiac and metabolic effects of anabolic-androgenic steroid abuse on lipids, blood pressure, left ventricular dimensions, and rhythm. PMID:20816133 (Link to Abstract)

Question Authors:

Jan Szatkowski MD, Patrick McCulloch MD, Ben Taylor MD,

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(SBQ07.45) A 17-year-old wrestler is noted to demonstrate increased aggression and hostility toward others at school. These are the most common behavioral side effects of what performance enhancing drug? Topic

Review Topic

1. Furosemide
2. Erythropoietin
3. Stanozolol
4. a-Ketoglutarate
5. Propranolol

PREFERRED RESPONSE ▶

DISCUSSION: Stanozolol, commonly sold under the name Winstrol (oral) and Winstrol Depot (intramuscular), is a synthetic anabolic steroid derived from dihydrotestosterone. Anabolic steroids are a class of performance enhancing drug taken to increase muscle mass and strength, reduce recovery time, and decrease muscle catabolism. These substances mimic the effects of testosterone and dihydroxytestosterone causing increased protein synthesis. Anabolic steroids have a long list of physiologic side effects including hypertension, liver disease, changes in cholesterol, and gynecomastia. The most commom behavioral side effects are agression, hostility, and violence.

The article by Hartgens is a review discussing the side effects of anabolic androgenic steroids.

The review article by Blue presents a concise summary of prevalence, efficacy, adverse effects, and legality of anabolic steroids.

Incorrect answers:
These may have a number of side effects, but aggression and hostility have not been shown to be common behavioral effects of these drugs.
1. Furosemide is the most commonly used banned diuretic in sports.
2. Erythropoietin stimulates increased red blood cell production and is used as a doping agent.
4. a-Ketoglutarate is a dietary supplement used by body builders that is claimed to improve athletic performance by removing excess ammonia from the body.
5. Propranolol is a Beta-blocker that athletes may use for its anxiety-reducing effects, resulting in steadier hands, an even heart rate and the increased ability to focus.

REFERENCES:

1. Hartgens F, Kuipers H. Effects of androgenic-anabolic steroids in athletes. Sports Med. 2004;34(8):513-54. PMID:15248788 (Link to Abstract)

2. Blue JG, Lombardo JA. Steroids and steroid-like compounds. Clin Sports Med.1999 Jul;18(3):667-89, ix. PMID:10410848 (Link to Abstract)

Question Authors:

Robert Boykin MD, Michael Hughes MD, Ben Taylor MD,

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(OBQ08.62) An athlete asks about performance enhancing substances. Which of the following side effects is more common with creatine than with testosterone? Topic

Review Topic

1. Muscle cramping
2. Hair loss
3. Testicle atrophy
4. Acne
5. Impotence

PREFERRED RESPONSE ▶

DISCUSSION: Muscle cramping is a side effect more common to creatine than testosterone. Testicular atrophy, acne and male patterned baldness are all associated primarily with testosterone use

In 2000, Terjung et al published a roundtable discussion of the physiological and health effects of oral creatine supplementation. They summarize a number of reports describing cramping, strains and stiffness in athletes taking creatine. This review also noted that creatine supplementation is associated with an enhanced accrual of strength in strength training programs and has been shown to enhance the ability to produce higher muscular force and/or power output during short bouts of maximal exercise.

The Schilling article is a retrospective review which found that athletes taking creatinine did not have significant health complaints compared to those who did not use creatinine.

REFERENCES:

1. Garrick JG (ed): OKU: Sports Medicine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 335-343

2. Terjung RL, Clarkson P, Eichner ER, Greenhaff PL, Hespel PJ, Israel RG, Kraemer WJ, Meyer RA, Spriet LL, Tarnopolsky MA, Wagenmakers AJ, Williams MH. American College of Sports Medicine roundtable. The physiological and health effects of oral creatine supplementation. Med Sci Sports Exerc. 2000 Mar;32(3):706-17. PMID:10731017 (Link to Abstract)

3. Schilling BK, Stone MH, Utter A, Kearney JT, Johnson M, Coglianese R, Smith L, O'Bryant HS, Fry AC, Starks M, Keith R, Stone ME. Creatine supplementation and health variables: a retrospective study. Med Sci Sports Exerc. 2001 Feb;33(2):183-8. PMID:11224803 (Link to Abstract)

Question Authors:

Patrick McCulloch MD, Guillem Lomas MD, Michael Hughes MD,

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(OBQ07.238) There is no presently accepted urine test to detect the use of which of the following performance-enhancing drugs? Topic

Review Topic

1. Ephedrine
2. Dihydroepiandosterone
3. Androstenedione
4. Human growth hormone
5. Tetrahydrogestrinone

PREFERRED RESPONSE ▶

DISCUSSION: Most governing bodies in sport use urine samples for drug testing. While there is a blood test to detect higher than normal levels of hGH, there is not presently a urine test. Accurate urine tests of the other performance enhancing drugs exist, but realize that new formulations that are undetectable by current tests can be developed and may be available to athletes. Answer 5, THG, was an example of a "designer steroid" in which the structure was changed in the lab so that it could not be detected on standard drug tests until a new test became available in 2003.

REFERENCES:

1. Calfee R, Fadale P. Popular ergogenic drugs and supplements in young athletes. Pediatrics. 2006 Mar;117(3):e577-89. PMID:16510635 (Link to Abstract)

2. Tokish JM, Kocher MS, Hawkins RJ. Ergogenic aids: a review of basic science, performance, side effects, and status in sports. Am J Sports Med. 2004 Sep;32(6):1543-53. PMID:15310585 (Link to Abstract)

Question Authors:

Patrick McCulloch MD, Eric Shirley MD,

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(OBQ07.268) The use of methandrostenolone for performance enhancement has been linked to all of the following EXCEPT. Topic

Review Topic

1. Decreased sperm count
2. Hypertension
3. Altered lipid profiles
4. Acne
5. Decreased vision

PREFERRED RESPONSE ▶

DISCUSSION: Methandrostenolone (Dianabol) is an anabolic steroid. This steroid was first commercially manufactured in 1960 and quickly became the most used and abused steroid worldwide, remaining so to date. It jokingly came to be known as "the breakfast of champions" in sports circles. A majority of users of anabolic steroids experience side effect including acne (40-54%), testicular atrophy (40-51%), gynecomastia (10-34%), cutaneous stria (34%), and injection site pain (36%). Hypertension, altered lipoprotein profile, and decreased sperm count are also common. The references are good reviews of performance-enhancing drugs and their effects.

REFERENCES:

1. Evans. Current concepts in anabolic-androgenic steroids. Am J Sports Med. 2004 Mar;32(2):534-42 PMID:14977687 (Link to Abstract)

Question Authors:

Patrick McCulloch MD,

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(OBQ05.215) What effect does glucagon have on skeletal muscle? Topic

Review Topic

1. Anabolic
2. Catabolic
3. No effect
4. Nootropic
5. Ergogenic

PREFERRED RESPONSE ▶

DISCUSSION: Glucagon is the hormone of fasting or starvation. In contrast to insulin, which promotes storage of nutrients when they are abundant, glucagon promotes mobilization and utilization of stored nutrients to maintain the blood glucose concentration in the fasting state; thereby it is catabolic to muscle. The major actions of glucagons are in the liver (in contrast to insulin, which acts on liver, adipose, and muscle tissue).

Juhn et al review the evidence-based ergogenic potential and adverse effects of 14 of the most common products in use by recreational and elite athletes today.

Incorrect Answers:
Answer 1: Anabolic means building up tissue (usually muscle).
Answer 4: Nootropics are purported to improve mental functions such as cognition, memory, intelligence, motivation, attention, and concentration.
Answer 5: Ergogenic aids are any external influences that can enhance performance.

REFERENCES:

1. Buckwalter JA, Einhorn TA, Simon SR (eds): Orthopaedic Basic Science: Biology and Biomechanics of the Musculoskeletal System, ed 2 Rosemont, IL., American Academy of Orthopaedic Surgeons, 2000. pp 683-716

2. Juhn M: Popular sports supplements and ergogenic aids. Sports Med 2003;33:921-939 PMID:12974658 (Link to Abstract)

Question Authors:

Greg Galano MD, Patrick McCulloch MD, Michael Hughes MD, Eric Shirley MD,

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(OBQ05.248) A 32-year-old professional cyclist suffered a heart attack 6 months ago secondary to long term anabolic steroid use. What is the mechanism by which steroids most likely caused this patient's heart disease? Topic

Review Topic

1. Increased blood hematocrit causing cardiac overload
2. Direct myocyte apoptosis
3. Alteration of plasma levels of low density lipoproteins
4. Alteration of myocardial conduction patterns
5. Hypertrophy of left ventricle

PREFERRED RESPONSE ▶

DISCUSSION: Anabolic steroid use causes decreased levels of HDL or "good" cholesterol, increased levels of LDL or "bad" cholesterol, and liver toxicity, along with a number of other side effects. Cases of acute myocardial infarction in steroid users are related to this change in plasma levels of low density lipoproteins which alters cardiac blood flow. As described by Silver in his review, the effect of anabolic steroids on muscle is caused by an increase in the production of proteins, thus increasing muscle mass. Second, steroids reduce recovery time by blocking the effects of the stress hormone cortisol on muscle tissue, reducing muscle catabolism.

REFERENCES:

1. Silver MD. Use of ergogenic aids by athletes. J Am Acad Orthop Surg. 2001 Jan-Feb;9(1):61-70. Review. PMID:11174164 (Link to Abstract)

Question Authors:

Patrick O'Donnell MD/PhD, Patrick McCulloch MD,

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Groups

ABOS II: Steroids & Stimulants

General - Oral Boards Review

7/29/2011

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Evidence & References Show References

Level of Evidence 4 (Case Series)

Schilling BK, Stone MH, Utter A, Kearney JT, Johnson M, Coglianese R, Smith L, O'Bryant HS, Fry AC, Starks M, Keith R, Stone ME. Creatine supplementation and health variables: a retrospective study. Med Sci Sports Exerc. 2001 Feb;33(2):183-8. PMID:11224803 (Link to Abstract)

Level of Evidence 5 and Other Journal Articles (includes Case Reports, Expert Opinions, Personal Observations, and Biomechanic Studies)

Hartgens F, Kuipers H. Effects of androgenic-anabolic steroids in athletes. Sports Med. 2004;34(8):513-54. PMID:15248788 (Link to Abstract)
Blue JG, Lombardo JA. Steroids and steroid-like compounds. Clin Sports Med.1999 Jul;18(3):667-89, ix. PMID:10410848 (Link to Abstract)
Terjung RL, Clarkson P, Eichner ER, Greenhaff PL, Hespel PJ, Israel RG, Kraemer WJ, Meyer RA, Spriet LL, Tarnopolsky MA, Wagenmakers AJ, Williams MH. American College of Sports Medicine roundtable. The physiological and health effects of oral creatine supplementation. Med Sci Sports Exerc. 2000 Mar;32(3):706-17. PMID:10731017 (Link to Abstract)
Juhn M: Popular sports supplements and ergogenic aids. Sports Med 2003;33:921-939 PMID:12974658 (Link to Abstract)
Silver MD. Use of ergogenic aids by athletes. J Am Acad Orthop Surg. 2001 Jan-Feb;9(1):61-70. Review. PMID:11174164 (Link to Abstract)

Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Garrick JG (ed): OKU: Sports Medicine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 335-343
Buckwalter JA, Einhorn TA, Simon SR (eds): Orthopaedic Basic Science: Biology and Biomechanics of the Musculoskeletal System, ed 2 Rosemont, IL., American Academy of Orthopaedic Surgeons, 2000. pp 683-716

Undefined

Hartgens F, Rietjens G, Keizer HA, Kuipers H, Wolffenbuttel BH. Effects of androgenic-anabolic steroids on apolipoproteins and lipoprotein (a). Br J Sports Med 2004;38:253-259. PMID:15155420 (Link to Abstract)
Blue JG, Lombardo JA: Steroids and steroid-like compounds. Clin Sports Med 1999;18:667-689. PMID:10410848 (Link to Abstract)
Hartgens F, Kuipers H: Effects of androgenic-anabolic steroids in athletes. Sports Med. 2004;34(8):513-54 PMID:15248788 (Link to Abstract)
Achar S, Rostamian A, Narayan SM. Am J Cardiol. 2010 Sep 15;106(6):893-901. Cardiac and metabolic effects of anabolic-androgenic steroid abuse on lipids, blood pressure, left ventricular dimensions, and rhythm. PMID:20816133 (Link to Abstract)
Calfee R, Fadale P. Popular ergogenic drugs and supplements in young athletes. Pediatrics. 2006 Mar;117(3):e577-89. PMID:16510635 (Link to Abstract)
Tokish JM, Kocher MS, Hawkins RJ. Ergogenic aids: a review of basic science, performance, side effects, and status in sports. Am J Sports Med. 2004 Sep;32(6):1543-53. PMID:15310585 (Link to Abstract)
Evans. Current concepts in anabolic-androgenic steroids. Am J Sports Med. 2004 Mar;32(2):534-42 PMID:14977687 (Link to Abstract)
Tokish JM, Kocher MS, Hawkins RJ. Ergogenic aids: a review of basic science, performance, side effects, and status in sports. Am J Sports Med. 2004 Sep;32(6):1543-53. PMID:15310585 (Link to Abstract)

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Steroids & Stimulants

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