Health risks

CONSEQUENCES OF DOPING ON ATHLETE’S HEALTH

Since 2004, and as mandated by World Anti-Doping Code, WADA has published an annual List of Prohibited Substances and Methods (List). The List, which forms one of the six International Standards, identifies the substances and methods prohibited in- and out-of-competition, and in particular sports. The substances and methods on the 2020 WADA Prohibited List are classified by different categories:

S0Non-approved substances
S1Anabolic Agents
S2Peptide hormones, growth factors, related substances and mimetics
S3Beta-2 agonists
S4Hormone and metabolic modulators
S5Diuretics and masking agents
S6Stimulants
S7Narcotics
S8Cannabinoids
S9Glucocorticoids
M1-M2-M3Prohibited Methods

ANABOLIC STEROIDS

Misuse of supraphysiological doses of anabolic steroids is claimed to have serious side effects. The causes of premature death among the powerlifters were suicide, acute myocardial infarction, hepatic coma and non-Hodgkin's lymphoma. These findings add to the growing amount of evidence of an association between anabolic steroid abuse and premature death, and support the view that measures to decrease AAS misuse among both competitive and amateur athletes are justified.

Among anabolic steroids, the drugs most frequently taken (often orally, sometimes intramuscular) are: stanozolol, oxandrolone, testosterone, oxymetholone, oxymesterone, and nandrolone, which is probably the most widely used. Various cardiac adverse events have been reported with the use of these drugs: cerebral thromboembolism due to intraventricular thrombi, myocardial infarction without coronary thrombus, sudden death due to hypertrophic cardiomyopathy and myocarditis during sports activity; a particular, reversible form of hypertrophic cardiomyopathy has also been observed. M. Pärssinen, U. Kujala, E. Vartiainen, S. Sarna, T. Seppälä, Increased Premature Mortality of Competitive Athletes Suspected to Have Used Anabolic Agents. Unit for Sports and Exercise Medicine, Institute of Biomedicine, University of Helsinki, 2000.

PEPTIDE HORMONES, STIMULANTS, NARCOTICS, ANABOLIC AGENTS, MIMETICS, DIURETICS, MASKING AGENTS

Cardiac arrhythmias are among the most important causes of non-eligibility to sports activities, and may be due to different causes (cardiomyopathies, myocarditis, coronary abnormalities, valvular diseases, primary electrical disorders, abuse of illicit drugs).

The list of illicit drugs banned by the International Olympic Committee and yearly updated by the World Anti-Doping Agency includes the following classes: stimulants, narcotics, anabolic agents (androgenic steroids and others such as beta-2 stimulants), peptide hormones, mimetics and ana- logues, diuretics, agents with an antiestrogenic activity, masking agents.

Almost all illicit drugs may cause, through a direct or indirect arrhythmogenic effect, in the short, medium or long term, a wide range of cardiac arrhythmias (focal or reentry type, supraventricular and/or ventricular), lethal or not, even in healthy subjects with no previous history of cardiac dis- eases. Therefore, given the widespread abuse of illicit drugs among athletes, in the management of arrhythmic athletes the cardiologist should always take into consideration the possibility that the ar- rhythmias be due to the assumption of illicit drugs (sometimes more than one type), especially if no signs of cardiac diseases are present. On the other hand, in the presence of latent underlying ar- rhythmogenic heart disease including some inherited cardiomyopathies at risk of sudden cardiac death, illicit drugs could induce severe cardiac arrhythmic effects. Arrhythmogenic effects of illicit drugs in athletes. Francesco Furlanello, Stefano Bentivegna, Riccardo Cappato, Luigi De Ambroggi Center of Clinical Arrhythmia and Electrophysiology, Istituto Policlinico San Donato, University of Milan, San Donato Milanese (MI), Italy, 2003.

BETA-2-AGONISTS

The commonly used beta-2-receptor agonists are: salbutamol, salmeterol, formoterol, terbutaline and clenbuterol. The IOC considers them as “anabolic agents” and “stimulants” (classes C and A, Table I), used to increase the muscle mass and physical strength. Beta-2-agonists may induce ventricular and supraventricular ectopic beats, as well as focal and reentry arrhythmias, supraventricular and ventricular, especially in subjects with underlying cardiomyopathies and in case of concomitant administration with other drugs. Arrhythmogenic effects of illicit drugs in athletes. Francesco Furlanello, Stefano Bentivegna, Riccardo Cappato, Luigi De Ambroggi. Center of Clinical Arrhythmia and Electrophysiology, Istituto Policlinico San Donato, University of Milan, San Donato Milanese (MI), Italy, 2003.

GROWTH HORMONE AND INSULINA-LIKE GROWTH FACTOR

They are instead widely used in the exogenous recombinant forms (rhGH and rhIGF-I) by athletes as anabolic agents, to increase the muscle mass, cardiac performance and stamina on the job, even though the real effect on muscle strength is still subject of debate. Up to now no side effects related to GH abuse are clearly known, but a significant increase in mortality was reported among patients submitted to treatment for catabolic diseases. With regard to athletes taking these drugs for a long time and at high dosages the following side effects are possible: systemic disorders such as myalgia, asthenia, headache, arthralgia, diabetes mellitus, thyroid disorders, acromegaly, metabolic ionic alterations; hypertension and various types of cardiomyopathies (hypertrophic or dilated), similar to those observed in acromegaly. All these conditions may contribute, to a variable extent, to the development of different types (focal or reentry) of supraventricular and ventricular arrhythmias, which are often found in athletes. Arrhythmogenic effects of illicit drugs in athletes. Francesco Furlanello, Stefano Bentivegna, Riccardo Cappato, Luigi De Ambroggi. Center of Clinical Arrhythmia and Electrophysiology, Istituto Policlinico San Donato, University of Milan, San Donato Milanese (MI), Italy, 2003.

DIURETICS

Diuretics are classes of heterogeneous substances prohibited by the IOC. Diuretics (class E, Table I) are often taken to mask the assumption of other drugs excreted in the urine (class G): the purpose is to attempt to dilute those drugs the cut-off urinary concentration of which is evaluated in tests for doping control (e.g., stimulants, narcotics and anabolic steroids such as nandrolone, methandienone metabolites, methyltestosterone, stanazolol). The administration of diuretics may cause arrhythmias due to hypokalemia and dehydration. Moreover, these arrhythmias may be particularly severe in case of underlying primary or “toxic” cardiac diseases. Arrhythmogenic effects of illicit drugs in athletes. Francesco Furlanello, Stefano Bentivegna, Riccardo Cappato, Luigi De Ambroggi. Center of Clinical Arrhythmia and Electrophysiology, Istituto Policlinico San Donato, University of Milan, San Donato Milanese (MI), Italy, 2003.

STIMULANTS

Besides cocaine, this group (class A, Table I) encompasses many other drugs, in particular amphetamines (ephedrine, methylephedrine, pseudoephedrine, caffeine and related substances), widely used among competitive athletes for their well-known effects: performance enhancement, increased level of aggressiveness, better standing of strain perception. Stimulants may cause focal and reentry arrhythmias, ventricular and supraventricular ectopic beats, atrioventricular nodal reentry tachycardia, focal atrial tachycardia, atrial fibrillation, ventricular tachycardia and fibrillation.

Their assumption may prove particularly hazardous in athletes with the Wolff-Parkinson-White syndrome (even in the subgroups of Wolff-Parkinson-White patients previously considered at low risk) because of the increase in atrial and ventricular excitability and the shortening of the accessory pathway refractoriness, with possible consequent fast atrial fibrillation and ventricular fibrillation. Arrhythmogenic effects of illicit drugs in athletes. Francesco Furlanello, Stefano Bentivegna, Riccardo Cappato, Luigi De Ambroggi. Center of Clinical Arrhythmia and Electrophysiology, Istituto Policlinico San Donato, University of Milan, San Donato Milanese (MI), Italy, 2003.

ERYTHROPOIETIN

EPO enhances oxygen transfer and tissue availability, increasing its arterial blood concentration, by raising the hemoglobin and red cell levels. In the bone marrow it stimulates erythroid precursors (but also regulates apoptosis), according to the physiologic inputs of oxygen requirements from the interstitial renal tubular cells. The long-term use of rhEPO and darbopoietin is characterized by many side effects. The increase in the total number of red cells leads to a rise in blood viscosity, which in athletes could be further exacerbated by natural perspiration during intense athletic performances. Besides, due to their actions on the endothelium and platelets, the thromboembolic risk could be increased in predisposed subjects, with cases of hypertension, myocardial infarction and stroke. This could be associated with the potential development of serious hematologic disorders such as acute leukemia, polycythemia and marrow aplasia. Arrhythmogenic effects of illicit drugs in athletes. Francesco Furlanello, Stefano Bentivegna, Riccardo Cappato, Luigi De Ambroggi. Center of Clinical Arrhythmia and Electrophysiology, Istituto Policlinico San Donato, University of Milan, San Donato Milanese (MI), Italy, 2003.

CANNABINOIDS

Cannabis has potential impact on the health of athletes as well as on performance in both training and in competition. Some synthetic cannabinoids have some substances that induce the reddening of the conjunctivae, increased pulse rate and xerostomia. Other reported effects of synthetic cannabinoid use include tachycardia, paranoia, agitation, hallucinations, vomiting, alterations in mood and perception, and a sense of being impaired.

Cannabis and the Health and Performance of the Elite Athlete, Mark A. Ware, Dennis Jensen, Amy Barrette, Alan Vernec and Wayne Derman. Clinical Journal of Sport Medicine, 2018.

GLUCOCORTICOIDS

It provides a sensation of strength and stamina on the job, improving exercise duration. The side effects in case of long-lasting treatments are corticosteroid-like and include obesity, hyperglycemia, osteoporosis, immunodeficiency, hypertension, and metabolic disorders. Arrhythmias may result mainly from cardiac hypertrophy, metabolic and ionic disorders. Arrhythmogenic effects of illicit drugs in athletes. Francesco Furlanello, Stefano Bentivegna, Riccardo Cappato, Luigi De Ambroggi. Center of Clinical Arrhythmia and Electrophysiology, Istituto Policlinico San Donato, University of Milan, San Donato Milanese (MI), Italy, 2003.

SOCIAL CONSEQUENCES

A positive test can have a significant effect on an athlete’s entire life, because as well as being dangerous to one’s health, doping can result in a loss of standing, respect and credibility, and often, the media and public will not believe a negative test in the future. A bad image sticks in the consciousness, and the athlete becomes isolated. However, doping offenders cheat not only other people, but themselves, too.