HGH… be like Ryan

Monday, July 29, 2013

“I’m not a role model. I’m paid to wreak havoc on the basketball court.”  Charles Barkley

“Charles…I don’t think it’s your decision to make. We don’t choose to be role models, we are chosen. Our only choice is whether to be a good role model or a bad one.”  Karl Malone

In 1993, a controversy arose when Mr. Barkley, now a television analyst declared that his job was to play basketball, not necessarily set an example for kids and others in his fan base. His comments came in an era when Nike wanted people to “be like Mike” and buy all things Jordan. Kids tried to copy the moves of their favorite player on the court, in the batter’s box and in the end zone. Twenty years later, the sports hero worship has taken a sad turn and Ryan Braun has become the latest poster child for bad behavior. His tacit admission to abusing performance enhancing drugs and suspension from baseball involves a drug mill in Florida and the revelation that the same clinic was supplying high school kids with HGH and testosterone. Be like Ryan?

Steroid abuse to enhance athletic performance has been a cat and mouse game for decades. Backroom chemists would create a designer steroid that perhaps might not be able to be detected by available drug tests. Athletes would cycle the use of the drugs they put into their bodies, hoping to test clean when their time came to present for urine or blood tests. An industry evolved to mask the presence of an illegal substance and a Google search could find thousands of sites with purported expertise. The advent of “forever young” clinics, promising eternal youth for those who could not come to terms with aging, put anabolic steroids into the mainstream and on Main Street. How could a doctor and clinic prescribe a medication unless it was proven effective, reliable and safe? Welcome to the concept of off-label prescribing.

Human growth hormone (HGH), also known as somatotropin, is produced in the brain’s pituitary gland and is responsible for cell growth and regeneration in the body. It is an anabolic hormone, responsible for increasing height in childhood but is also a major player in muscle development, blood sugar regulation, calcium metabolism, protein production and fat breakdown. For all that it can do in the body, there are very few medical indications for it to be prescribed by a physician.

Pediatrics: Treatment of children with growth failure due to growth hormone deficiency, Prader-Willi syndrome, small for gestational age, Turner syndrome and idiopathic short stature

Adult: treatment of adults with either adult onset of childhood onset of growth hormone deficiency

That’s it. These are the only approved uses of HGH. But once a drug is on the market, a physician can choose to prescribe it off-label. Supposedly, the doctor needs to balance the benefits and risks of using a medication that has not been tested and approved for a specific condition. This is a long honored tradition in medicine and many medications have been recognized for their unintended benefit and have become routine treatments. Erythromycin, an antibiotic, seems to help patients with diabetic gastroparesis, where the stomach doesn’t empty appropriately. Reglan and Compazine, two medications used to control nausea, also seem to abort migraine headaches when injected intravenously.

Off label HGH use to improve athletic performance somehow seems different. HGH allows muscle to recover from injury and overuse, letting players train more aggressively. It can promote lipolysis, breaking down fat stores in the body and may increase lean body mass by increasing the amount of water in muscles cells, but not necessarily increasing the size or number of muscle cells in the body. This is not a wonder drug. There are significant risks that include leukemia, high blood pressure, atherosclerosis, diabetes, thyroid disease and liver and pancreas problems.

Biogenesis, the suspect Florida clinic that was the source of HGH and other hormones to pro athletes, also seemed to have a younger clientele. High school athletes are alleged to have been patients receiving performance enhancing drugs with all the attendant risks that come with taking a drug your body does not need. These were not back alley dealings but instead, parents would escort their kids to Biogenesis in hopes of them becoming the next Ryan Braun.

A year before Charles Barkley demanded that parents and other take the role model responsibility, Lyle Alzado, a Pro Bowl football player and self-admitted anabolic steroid user died of a brain tumor and his portrait on the cover of Sports Illustrated became the face of steroid abuse in the NFL.  He repented his drug abuse and urged others not to follow in his steps. We have not learned from history. The golden ring of professional athlete stardom has caused performance enhancing drugs have filtered from the pros to college to high school and slowly into middle school.

Mr. Braun’s reputation will be the most significant consequence of his drug abuse admission but he has a job playing baseball next year and $100 million awaiting him in salary. For every Ryan Braun, there are too man to count players who don’t make the major leagues or even their college team. For them, the consequences may be broken and damaged bodies that will cause them to suffer a lifetime.

Be like Ryan?

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when legal is not allowed

Monday, June 10, 2013

The story says that Major League Baseball has reached an agreement with the owners of Biogenesis, a now defunct clinic in Florida, who allegedly supplied performance enhancing drugs to numerous players, including stars like Alex Rodriguez and Ryan Braun. Guilt by association has now been established, regardless how the story ends. However, while baseball may not like human growth hormone (marketed by Pfizer as Genotropin), HGH is a legal medication, available to appropriate patients by prescription. The issue for sport and society is how to explain to young athletes and their families, the risk and rewards of using a medication that has very real adverse side effects.

The story needs to start with a doctor having the power to write a prescription for a medication. While the pharmaceutical company lists the indications for which that drug is approved, once it is on the market, a doctor can prescribe it for any patient they see fit, but it is patient (and physician) beware, since studies may not have been done to establish “off label” benefit or risk. There are success stories and off-label can enter the norm. For example, erythromycin, an antibiotic, may work to help diabetic patients whose stomachs don’t empty well and metoclopramide (Reglan) used for nausea and vomiting, when injected intravenously, is now used routinely to treat migraine headaches. There is power in the doctor’s pen or computer keyboard to sign prescriptions, matching diagnosis and treatment, regardless of the science that may or may not exist.

Back to HGH. Human growth hormone is normally produced in the pituitary gland located in the brain. It circulates in the blood stream and stimulates liver cells to produce Insulin Growth Factor 1 (IGF-1), the active ingredient that stimulates growth. Almost all cells have IGF-1 receptors, being especially active on bone, cartilage and muscle, as well as nerve, bone marrow and lung cells, regulating cell growth and development.

In children, without adequate HGH being produced in the brain, IGF-1 levels are not adequate to promote growth and short stature may occur. The cause may be genetic, acquired (for example a head injury or tumor) or idiopathic, where the cause is unknown. In adults, the only indications are decreased HGH levels because of pituitary disease, hypothalamus disease (the gland that stimulates the pituitary), surgery, radiation therapy or trauma. That has not stopped the new anti-aging industry from promoting HGH as the new fountain of youth. In non-mammals, IGF-1 can slow aging but that research has yet to be proven in mammals, let alone humans.

The ability to compete at a high level in sports requires genetic predisposition, talent and a lifetime of work. Fans reward that dedication and athletes reap the rewards of adulation and money. The use of performance enhancing drugs may unlevel the playing field and the trickle-down effect may cause unintended, significant side effects to the users. When college players feel the need to use HGH to compete with the pros, it causes high school players to consider its use to compete for scholarships. The statistics say that up to 10% of high school athletes have tried anabolic steroids.

The problem is in the side effects. In teens that are still growing, complications of HGH use include scoliosis, if there is already a potential, and slipped femoral capital epiphysis, a fracture through the growth plate of the hip. Other issues include unmasking diabetes, hypothyroidism, pancreatitis, raised pressure within the brain and increasing the cancer risk in some patients. In addition, there can be significant skin swelling, muscle and joint pains, including carpal tunnel syndrome. And then there is the increased mortality rate in acutely ill patients who are using HGH.

The use of HGH and other performance enhancing drugs is banned in baseball. Their use is considered cheating presumably because of the risk to the player. Other performance enhancements, like eye surgery to improve vision, are allowed. On the field, some rules are allowed to be broken. It is “allowable” to throw a spitball or otherwise doctor the ball, as long as you are not caught (Gaylord Perry, Hall of Famer) or the fans can be forgiving for using a corked bat (Graig Nettles, Albert Belle).

For many athletes, the lure large sums of money and the fame of pro sports career, outweighs the real risk that comes with the use of performance enhancing drugs. The sad news is that there are very few who will make the big leagues and the many who have not climbed the ladder, will feel the physical consequences of their drug use without tasting success. A sport may deem drug use unacceptable, but pressure to win may override that decision, especially when the use of that drug is legal.

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