L6 - MLS Drug Testing in Sports.2023.handout.pdf

Drug Testing in Sports Graham R. Jones, Ph.D. Former Chief Toxicologist Office of the Chief Medical Examiner and Clinical Professor, Faculty of Medicine and Dentistry 1 [email protected] History • Doping in sports dates back centuries to Greek and Roman events • In 1800s, strychnine, cocaine a...

Drug Testing in Sports Graham R. Jones, Ph.D. Former Chief Toxicologist Office of the Chief Medical Examiner and Clinical Professor, Faculty of Medicine and Dentistry 1 [email protected] History • Doping in sports dates back centuries to Greek and Roman events • In 1800s, strychnine, cocaine and caffeine known to be used • Modern ‘dope testing’ started in mid-1960s after British cyclist Tommy Simpson collapsed and died after a grueling race: dehydration and methamphetamine use • Initial ‘dope testing’ focused mainly on stimulants 2 Current Regulation • International Olympic Committee (ICO) • World Anti-Doping Agency (WADA, 2002) • International Sporting Agencies (e.g. IAAF) • Regional Events (e.g. Pan American Games, World University Games, Commonwealth Games) • National (e.g. Canadian Olympic Committee), other regional, local 3 Terms • Prohibited Substances • Some sports specific • Some allowed out-of-competition • Monitoring Program • To monitor potentially abused drugs • Therapeutic Use Exemption (TUE) • Specific exemption for medically justified medications that would otherwise be banned 4 Therapeutic Use Exemption • Certain drugs may be allowed in some formulations if recommended by physician AND approved by WADA • Approved, screened use of specific medications for legitimate medical purposes • Must be approved BEFORE use (during or out-ofevent) • Athlete’s physician must apply to WADA medical team 5 Monitoring Program • To monitor incidence and concentrations of drugs not banned outright, but subject to abuse • 1. Stimulants: In-Competition only: Bupropion, caffeine, nicotine, phenylephrine, phenylpropanolamine, pipradrol and synephrine. • 2. Narcotics: In-Competition only: Hydrocodone, mitragynine, morphine/codeine ratio, tapentadol and tramadol. • 3. Glucocorticoids: In-competition (by routes of administration other than oral, intravenous, intramuscular or rectal) and Out-of- Competition (all routes of administration) • 4. Beta-2-agonists (Bronchodilators) – any combination of two. 6 Stimulants • Sympathomimetic effects: raised blood pressure, increased heart rate, greater endurance, combats fatigue, improved endurance • “Amphetamines” and most other drugs with stimulant effects (cocaine, strychnine, methylphenidate, cathinones…) • Used to be an absolute ban on all stimulants including mild stimulants but now ephedrine*, pseudoephedrine**, phenylpropanolamine and some other mild stimulants now allowed (but in monitoring program) • *Ephedrine allowed if <10 mg/l in urine • **Pseudoephedrine allowed if <150 mg/l in urine 7 Caffeine • Allowed now, but urine concentration originally was to be less than 12 mg/l • In 2009 on “monitored” list (still is) • Can be abused: • By non-coffee drinkers • Abstinence followed by use • Main desired “stimulant” effect is increased aggression 8 Bronchodilators (β2-agonists) • Most banned, except salbutamol, salmeterol, terbutaline and formoterol allowed in inhaled form if athlete is granted TUE for asthma or similar condition • Even with TUE, salbutamol must be <1000 ng/ml in urine, unless athlete can prove they have abnormal metabolism! 9 Narcotics • Main reason for ban is to protect the athlete (to prevent aggravation of an injury through competition) • Banned: morphine and most other pharmacologically related narcotics • Buprenorphine, dextromoramide, heroin, fentanyl and its derivatives, hydromorphone, methadone, morphine, oxycodone, oxymorphone, pentazocine, pethidine/meperidine • NSAIDS, acetaminophen, salicylate, and recently codeine permitted (but codeine:morphine ratio monitored), also allowed: hydrocodone, tramadol. 10 Beta-Blockers • Beta-adrenrgic blockers • Reduce blood pressure and are antiarrhythmic and include: • Propranolol, metoprolol, oxprenolol, atenolol, acebutolol, timolol • By reducing blood pressure and heart rate produces a “steadying effect” useful for sports such as shooting, biathlon, archery • Full list: Archery, Automobile, Billiards (all disciplines), Darts, Golf, Shooting, , Skiing/Snowboarding in ski jumping, freestyle aerials/halfpipe and snowboard halfpipe/big air, Underwater sports 11 Diuretics • Diuretics actively promote excretion of water via the kidneys, including: • furosemide, hydrochlorthiazide, chlorthiazide and many others • Two main uses: • Reduce body weight in “weight class” sports (e.g. boxing) • Produce dilute urine in a bid to avoid detection of banned drugs 12 Anabolic Steroids • Rarely used medically – mainly in diseases involving severe muscle wasting • Bolasterone, nandrolone, stanozolol, methandionone, methyltestosterone, etc., etc. • Main desired effects are increased muscle mass, possibly increased strength, and increased aggression • Serious side effects from use of massive doses include stunted growth, defeminizing of females (androgenic effects), demasculinizing of men (suppression of testosterone synthesis?), impaired liver function, heart disease and cancer 13 Testosterone • Use started as tests for synthetic anabolics became better • Primarily an androgenic steroid with minor anabolic effects • Testing started for: • testosterone (T): epi-T ratio. Normally 1:1. More than 4:1 regarded as suspicious and possible sanctions • T and Epi-T abuse started • Also >150 ug/l “T” in urine “suspicious” • Now labs may look at C12:C13 ratio 14 Hormone and metabolic modulators* • Aromatase inhibitors: • Prevents excess testosterone from being converted to estrogen • aminoglutethimide; anastrozole; androsta-1,4,6-triene-3,17-dione (androstatrienedione); 4-androstene-3,6,17 trione (6-oxo); exemestane; formestane; letrozole and testolactone. • Other anti-estrogenic substances: • clomiphene; cyclofenil and fulvestrant. • Selective Estrogen Receptor Modulators (SERMs): • Inhibits the action of estrogen on estrogen receptor • raloxifene; tamoxifen and toremifene. • Selective Androgen Receptor Modulators (SARMs): • Have anabolic effects with minimal androgenic effects • Some in clinical or pre-clinical trial; available illicitly • Agents modifying myostatin function(s): • myostatin inhibitors (leads to increased muscle mass) • Metabolic modulators (increases exercise endurance): • Activators of the AMP-activated protein kinase (AMPK), e.g. AICAR; and Peroxisome Proliferator Activated Receptor δ (PPARδ) agonists, e.g. GW 1516; • Insulins; Trimetazidine. 15 SERMs* • Selective estrogen receptor modulators (SERMs) are a class of compounds that act on the estrogen receptor. A characteristic that distinguishes these substances from pure receptor agonists and antagonists is that their action is different in various tissues…. • A SERM prevents estrogen from binding to receptors by binding itself to the receptors in its place which can be very advantageous. By its mode of action a SERM stimulates the release of Luteinizing and Follicle Stimulating Hormones (LH & FSH) by which when stimulated for release, in-turn, cause the production and release of testosterone throughout the body. • SERMs also help block the paradoxical feminizing effects of testosterone caused by excess estrogen and resulting hypogonadism (due to lack of sufficient testosterone). 16 Selective Androgen Receptor Modulators (SARMs)* 17 Ligandrol – a SARM* • Ligandrol (VK5211, LGD-4033) is an investigational selective androgen receptor modulator (SARM) for treatment of conditions such as muscle wasting and osteoporosis • Can stimulate muscle growth. SARMs have shown superior side effect profiles compared to anabolic steroids • Lapointe remarked that the National Team Training Centre purchased nutritional supplements for its athletes and denied buying or taking nutritional supplements on her own • On 23 October 2017, a nutritional supplement company in Missouri called Infantry Labs was warned by the FDA that the distribution of two of its products violated the Federal Food, Drug, and Cosmetic Act. One of the substances was ligandrol. The company advertised as benefits of the ligandrol: "increases in lean body mass and decrease in body fat" and "increases in strength, well being, as well as healing possibilities“. • Wikipedia 2019 18 British relay team mates lose Olympic silver over Ujah's doping test* • Aug 14 2021(Reuters) - The Athletics Integrity Unit said on Thursday Ujah has been provisionally suspended for allegedly breaching anti-doping rules at the Tokyo Games after he had returned an Adverse Analytical Finding (AAF) from a test carried out during the Olympics. read more • It listed the prohibited substances detected as Ostarine and S-23, both classified by world anti-doping organisation WADA as a selective androgen receptor modulator (SARM) with effects similar to anabolic steroids. 19 Other Hormones… • Chorionic Gonadotrophin (CG) and Luteinizing Hormone • (LH) and their releasing factors, e.g. buserelin, gonadorelin and triptorelin, in males; • Corticotrophins and their releasing factors, e.g corticorelin; • Growth Hormone (GH) and its releasing factors including • Growth Hormone Releasing Hormone (GHRH) and its analogues, e.g. CJC-1295, sermorelin and tesamorelin; Growth Hormone Secretagogues (GHS), e.g. ghrelin and ghrelin mimetics, e.g. anamorelin and ipamorelin; and GH-Releasing Peptides (GHRPs), e.g. alexamorelin, GHRP-6, hexarelin and pralmorelin (GHRP2). • Additional prohibited growth factors: • Fibroblast Growth Factors (FGFs); Hepatocyte Growth Factor (HGF); Insulin-like Growth Factor-1 (IGF-1) and its analogues; Mechano Growth Factors (MGFs); Platelet-Derived Growth Factor (PDGF); Vascular-Endothelial Growth Factor (VEGF) and any other growth factor affecting muscle, tendon or ligament protein synthesis/degradation, vascularisation, energy utilization, regenerative capacity or fibre type switching. 20 Other drugs… • Alcohol (some sports; 10 mg/100 ml limit) • Air Sports, Archery, Automobile, Powerboating • Cannabis & synthetics (now all sports) • Except cannabidiol CBD! • Glucocorticosteroids (except topical) • and • Gene doping! • The following, with the potential to enhance sport performance, are prohibited: • 1. The transfer of polymers of nucleic acids or nucleic acid analogues; • 2. The use of normal or genetically modified cells. 21 Soda Loading • Athlete consumes large amounts of alkali such as sodium bicarbonate to increase the “base reserve” of the body and delay the onset of lactic acid buildup and “the cramps” • Nothing to do with soda-pop!!! 22 Blood Doping • Administration of their own or someone else’s blood prior to competition • To increase oxygen carrying capacity of the body • Side effect: erythrocythemia (and clotting), even if crossmatching not an issue (i.e. athlete’s own packed cells) 23 Erythropoietin (EPO) • Regulates final maturation of bone marrow cells and stimulates early release of reticulocytes into the circulation • Can be used a week or so prior to event to stimulate red cell production; EPO level falls before red cell levels fall to normal • Synthetic recombinant EPO used medically • Abuse was difficult to detect • Recombinant EPO now detectable based on different isoelectric point 24 ESAs AND MIMETICS* • ESA - erythropoiesis-stimulating agents • 1. Erythropoietin-Receptor agonists: • 1.1 Erythropoiesis-Stimulating Agents (ESAs) including e.g. darbepoietin (dEPO); erythropoietins (EPO); EPO-Fc; EPO-mimetic peptides (EMP), e.g. CNTO 530 and peginesatide; and methoxy polyethylene glycolepoetin beta (CERA); • 1.2 Non-erythropoietic EPO-Receptor agonists, e.g. ARA-290, asialo EPO and carbamylated EPO • 2. Hypoxia-inducible factor (HIF) stabilizers • e.g. cobalt; FG-4592; HIF activators such as argon, xenon, krypton • Hypoxia-inducible factor 1-alpha, also known as HIF-1-alpha, is a protein that in humans is encoded by the HIF1A gene 25 More about HIF stabilizers* • Hypoxia-inducible factor stabilizer (HIF stabilizer) is a pharmaceutical used to treat chronic kidney disease. Like most transcription factors, the HIF transcription factor is responsible for the expression of a protein. The HIF stabilizer activates the activity of EPO due to anemia induced hypoxia, metabolic stress, and vasculogenesis—the creation of new blood vessels. HIF stabilizers as used by cyclists in combination with cobalt chloride/desferrioxamine stimulate and deregulate the natural production of erythropoietin hormone. At physiologically low PaO2 around 40 mmHg, EPO is released from the kidneys to increase hemoglobin transportation. The combination of drugs consistently releases EPO due to increased transcription at the cellular level. The effect wears off when the HIF stabilizers, cobalt chloride/desferrioxamine is excreted and/or decayed by the body. (Source: Wikipedia – Blood Doping page!) 26 Masking Agents • Diuretics • Cause dilute urine, indirectly ‘masking’ the presence of various drugs, including anabolic steroid metabolites • Plasma Expanders (impairs detection of EPO) • • • • Albumin Dextran infusion Gelatin succinylated Hydroxyethyl starch 27 Athlete Biological Passport • The fundamental principle of the Athlete Biological Passport (ABP) is to monitor selected biological variables over time that indirectly reveal the effects of doping rather than attempting to detect the doping substance or method itself. • Anti-doping organizations can integrate the Athlete Biological Passport into the larger framework of a robust anti-doping program in order to: • Identify and target athletes for specific analytical testing by intelligent and timely interpretation of Passport data; and • Pursue possible anti-doping rule violations based on an atypical passport, in accordance with Article 2.2: Use or attempted use by an athlete of a prohibited substance or a prohibited method of the World Anti-Doping Code (Code). 28 Testing - Collection • In-Competition • • • • • • “Placed” individual finishers & teams, random finishers Continuous escort from completion of event Taken to doping control officer at assigned room Observed collection of urine sample Full and strict chain of custody “A” and “B” samples • Out-of-Competition • WADA representative may show up at any time, anywhere in the world!!!! 29 Testing – The Laboratory • Problem: have to look for ALL pharmacologically related drug available worldwide • GC/NP, GC-MS(/MS) and LC-MS/MS (normal and high resolution) • Testing must usually be completed within 24 hours (lab may operate 24 hours/day) • “Positives” must be re-analyzed by different personnel under observation of athlete (or rep) and sporting organization rep • Some testing (e.g. EPO) requires blood 30 Designer Steroids • Screening and confirmation of steroids and their metabolites relies on monitoring specific mass ions • Some are common to several steroids, others are specific for one steroid only • If you “custom design” another steroid, that steroid and/or its metabolites may become “invisible” • Examples: “East bloc labs”, California lab (Balco) 31 ‘Excuses’ • The lab must have “screwed up” • Those can’t have been my urine bottles • It must have been in something my “physician / coach” gave me • Must have been contamination of my “health” products • It must be a metabolite of a non-banned substance 32 Primary Drug Classes Abused in Sports Stimulants: ‘energy’, endurance e.g. amphetamines (caffeine - special case) Bronchodilators: facilitates respiration e.g. salbutamol, albuterol Beta blockers: ‘steadying effect’ (heart rate) e.g. propranolol, metoprolol Narcotics: banned for protection of the athlete e.g. morphine, hydromorphone Diuretics: dilutes urine, removes water from the body e.g. furosemide, hydrochlorothiazide Anabolic steroids: body/muscle building e.g. danabol, stanozolol, (testosterone); Growth hormones: promotes muscle formation e.g. growth hormone, chorionic gonadotropin, growth factors Glucocorticosteroids: bronchodilator, boosts energy, analgesic (not a medical effect) e.g. betamethazone, prednisone, prednisolone 33 Erythropoietin: boost oxygen carrying capacity; e.g. usually synthetic drug ‘Secondary’ Drug Classes Abused in Sports Anabolic stimulation SARMs Drugs that reduce anabolic side effects (e.g. block estrogen effects) Aromatase inhibitors; SERMs Agents inhibiting myostatin Promotes increased muscle mass Erythropoietin stimulation Erythropoiesis stimulating agents (ESAs) Hypoxic inducible factor (HIF) stabilizers, e.g. xenon, cobalt 34