Steroid Doping

Essentials

• Remember the possibility of anabolic steroid or testosterone use when a competitive athlete or a recreational or power athlete seeks medical treatment for acne, infertility, loss of sexual desire, cardiac symptoms, depression, uncontrolled outbursts of rage or sleep disturbances.
• The physician should be particularly alert if the patient has in addition a strong musculature, and other effects of anabolic steroids (e.g. high haemoglobin level) are apparent.
• Rule out the use of anabolic steroids before starting therapy for acne.
• Be alert to the possibility of heart diseases and even acute myocardial infarction in an anabolic steroid user.
• Obtaining a good patient history and creating a trusting doctor-patient relationship are crucial for investigations and treatment.

Preparations

• All anabolic steroids used for doping have both androgenic and anabolic properties. The range of non-medically used anabolic steroids on the black market includes, for example, the following:
• Nandrolone
  • After testosterone the most widely used injectable anabolic steroid
  • The names of preparations sold on the black market include Silabolin^® , Deca-Durabolin^® , Retabolin^® , Laurobolin^® and Deca-Bolin^® .
• Methandrostenolone
  • The most widely used peroral anabolic steroid
  • Sold as 5, 10 or 50 mg tablets on the black market with names such as Dianabol^® , Anabol^® , Anabolin^® , Methandrostenolon^® and Metabolin^® .
• Testosterone and derivatives
  • The most frequently confiscated anabolic substance
  • There are several preparations of East European origin on sale on the street. Commercial injectable preparations include Androxon^® , Estandron Prolongatum^® , Omnadren^® , Primodian-Depot^® , Primoteston-Depot^® , Restandol^® , Sustanon^® , Panteston^® , Testen^® , Testoviron depot^® and Undestor^® . The most popular preparation is Sustanon 250 of which there is a wide range of bogus products.
  • Testosterone undecanoate (Panteston^® ) is an orally administered testosterone derivative. Panteston is popular mainly among competing athletes.
• Drostanolone
  • Is used both as injectable and as tablets.
  • Trade names incude e.g. Masteron^® .
• Dehydrochlormethyltestosterone
  • Used as tablets
  • Trade names include e.g. Oral-Turinabol^® .
• Trenbolone
  • An injectable derivative of nandrolone, sold on the street as Parabolan^® and Finajet^® . Trenbolone does not aromatize and thus causes gynaecomastia less often than, e.g., testosterone.
• Stanozolol
  • Is used both as injectable and as tablets.
  • The most well-known trade names are Stromba^® and Winstrol^® .
• Boldenone
  • Injectable
  • Most well-known trade name is Equipose^®
• Oxymetholone
  • Used as tablets
  • The most well-known trade names are Anapolon^® , Anadrol^® and Androlic^® .
  • Like other anabolic steroids used as tablets, oxymetholone has a stronger effect on liver than anabolic steroids that are used as injections.
• Oxandrolone
  • Only as tablets; mostly under the trade name Anavar^®
• Fluoxymesterone
  • Used as tablets
  • The most well-known trade name is Halotestin^® .
• Substances prohibited in sports are listed in The Prohibited List by World Anti-Doping Agency (WADA) http://www.wada-ama.org/en/what-we-do/the-prohibited-list. Notice that the list is not exhaustive http://www.wada-ama.org/en/questions-answers/prohibited-list-qa#item-1409. Consult locally available sources or experts for more information on allowed substances.

Substances used in association with anabolic steroids

• Other substances are also often used in association with anabolic steroids, either to increase anabolic effects or to remove adverse effects. Such substances include, among others, the following:
• Tamoxifen, clomifen, anastrozole and letrozole
  • Oestrogen receptor antagonists, selective oestrogen receptor modulators (SERM) and aromatase inhibitors that are used to prevent gynaecomastia during use of anabolic steroids and to reduce the suppressing effect of steroids on one's own gonadotropin secretion.
  • Trade names e.g. Novaldex^® , Tadex^® , Clomifen^® , Arimidex^® and Femar^®
• Human chorionic gonadotropin
  • Is used to induce the body's own testosterone production at the end or near the end of abuse period.
  • The best know trade names are Pregnyl^® , Profas^® , HCG^® and Ovitrelle^® .
• Insulin
  • Insulin is used to increase the speed of replenishing muscular energy stores, i.e. to speed up recovery. In association with steroid doping the aim of insulin use is also to achieve anabolic effects and to reduce the insulin resistance caused by anabolic steroids and growth hormone use. Insulin overdose leads very rapidly to hypoglycaemia and unconsciousness.
• Clenbuterol
  • Oral beta-2 agonist used for treating asthma in horses. The most common names trade names are Ventipulmin^® , Spiropent^® , and Clenbuterol^® .
  • Increases the protein content in striated muscles and enhances the use of muscle glycogen and body fat stores. The size of the muscle cells is increased while their number remains the same.
  • Typically used in fitness sports during the preparatory phase before competitions.
  • Large doses of clenbuterol combined with anabolic steroids may cause tachycardia, myocardial ischaemia and arrhythmias.
• Growth hormone
  • Anabolic effect. Most common trade names, produced by DNA recombination technique, are Genotropin^® , Norditropin^® , Humatrope^® and Saizen^® .
  • The most often confiscated product is the Chinese Jintropin^® .
  • Causes arthralgia, oedema and cardiomyopathy.
• IGF-1 and LR3IGF-1
  • The use of these substances has increased as IGF-1 has been licensed for the treatment of short stature (mekasermin; Increlex^® ) and LR3IGF-1, which is in the experimental stage, has found its way to the assortment of companies specialized in black market sales in the Internet (e.g. Omega Laboratories and various Chinese companies).
  • The effects are similar to growth hormone and insulin. Potentially acutely life-threatening (hypoglycaemia).
• Substances that inhibit the activation of activin receptor type IIB
  • Increase muscular growth.
  • Receptor activation can be inhibited through several different mechanisms, for example by anti-receptor antibodies (e.g. bimagrumab) and myostatin inhibitors (e.g. follistatin, as well as myostatin-neutralizing antibodies, such as domagrozumab, landogrozumab, stamulumab).
  • Use of these drugs is, for the time being, probably at a low level, but if the substances currently used in clinical trials enter the market for the treatment of, for example, cachexia, they will be easier available and their use in doping will increase.
• Other substances used in association with steroid doping
  • Ephedrine and its derivatives for burning fat
  • Stimulants, such as amphetamine, are used to enhance training.
  • Thyroid hormones for burning fat
  • Among the various dietary supplements especially the so-called ”testosterone boosters” (which often contain precursors of testosterone and nandrolone) as well as dinitrophenol (DNP). DNP used as fat burner blocks cell respiration and is acutely life-threatening.

Common adverse effects

Investigations

• Plasma ALT, AST
• Plasma cholesterol, HDL-cholesterol
• Plasma triglycerides
• Liver ultrasound
• Semen analysis
• Serum testosterone, follicle stimulating hormone, luteinizing hormone, sex hormone binding globulin
• Echocardiography
• ECG, chest x-ray
• Standardized questionnaires e.g. to assess depression

Withdrawal

• Warning about the risks of steroid abuse
• The patient should be informed that giving up steroids after many weeks of use may cause tiredness, depression and impotence, but that the natural hormone production will resume to its earlier level within 3-12 months.
• Human chorionic gonadotropin may provide some help.
• The patient must be told that testosterone replacement therapy will prevent his/her own hormone production and restoration of sperm production.

Follow-up

• Serum sex hormone binding globulin, serum luteinizing hormone
• Monitoring of liver function as required
• Referral to a sports physician