New York Times - December 20, 2009
H.G.H.’s Conundrum: Does Costly Treatment Enhance
Performance?
By IAN AUSTEN
OTTAWA — While human growth hormone has a remarkable ability to
generate controversy, exactly what it does for athletes, both good and bad, is
as much of a mystery today as when it first found favor as a performance
booster during the 1990s.
“That’s uncharted
territory,” said Richard J. Auchus, a professor of endocrinology at the University of
Texas Southwestern Medical School in Dallas. “We just don’t know
what happens when people use high doses for long periods of time.”
H.G.H. is among the
drugs prescribed by Anthony Galea, a Toronto-based sports medicine
physician who was charged by the Royal Canadian Mounted Police last week with,
among other things, conspiring to smuggle it into the United States. H.G.H. is
legal in Canada but approved in the United States for only a few specific uses
that do not include hastening recovery from injuries.
Galea has treated a
number of elite athletes, including Tiger Woods, the sprinter Donovan Bailey and the swimmer Dara Torres, and is being investigated by
American authorities for supplying performance-enhancing drugs to athletes in
the United States. Both Galea and his lawyer have strongly rejected that
allegation and dispute the Canadian charges.
Galea told The New
York Times before being charged that he had never given an athlete growth
hormone. But he acknowledged that he prescribed the drug to some patients at
his Toronto clinic who were at least 40 and fatigued. Galea, 50, is such a
believer in its restorative powers that he said he had injected the hormone
into his body five days a week for the last decade.
But physicians and
medical researchers who have studied people with medical conditions that lead
to growth hormone overproduction said that available evidence suggested that
athletes who cheat by using costly H.G.H. may simply wind up being cheated
themselves.
“Ultimately I’d have
to say that its main effect is that it makes your wallet a little less heavy,”
said Dr. Alan D. Rogol, a professor emeritus of endocrinology at the University of Virginia. Rogol also reviews
requests to the United States Anti-Doping Agency from athletes
seeking permission to use banned hormones for therapeutic treatments.
Suspicions that
athletes may be using growth hormone first surfaced in the 1980s. But at the
time, the only source of the hormone was cadavers.
Advances in genetics, however, allowed biotechnology
companies to clone and market several hormones, including H.G.H., beginning in
the 1990s. Those products swiftly found an illicit following among athletes.
H.G.H. is considered a performance-enhancer in sports, and the World Anti-Doping
Agency subsequently banned it.
The hormones came with
a long list of side effects. For H.G.H., they include cardiovascular problems,
an increased risk of diabetes, arthritis, carpal tunnel syndrome, glucose intolerance, colon polyps, skin growths, excessive sweating and serious headaches. Heavy and
prolonged growth hormone use can lead to abnormal bone growth in the face,
head, hands and feet. It is widely suspected, but not proved, that excessive
H.G.H. may promote cancers.
Despite Galea’s
practice for older patients, growth hormone injections ultimately leave users
fatigued, said Auchus, who acts as the Endocrine Society’s spokesman on hormone
abuse. “Rather than being some fountain of youth, the older you are the less
you tend to benefit,” Auchus said.
The United States
determined that potential harm from H.G.H. is so great that federal law puts it
in an unusual category of drugs that doctors cannot prescribe for unapproved,
or off-label, uses. (No such ban exists in Canada.) Its approved uses are not
conditions common among professional athletes: it can be used in children with
severe growth problems, H.I.V. patients may receive it if they have muscle wasting, and it can be prescribed to
offset exceptional weight loss in people who have had much of their small
intestine surgically removed.
When it came to
doping, the new hormones had an attractive feature. Because they are clones of
natural hormones, they were invisible to antidoping tests that relied on
looking for chemical abnormalities in urine samples. Although a blood test for
H.G.H. was subsequently developed, it has not been highly effective. Rogol said
that it only worked if the test subject had injected H.G.H. shortly before
being asked for a sample.
Some of the cloned
hormones unquestionably enhance performance. Erythropoietin, or EPO, boosts red blood cells, offering athletes
in endurance sports significant gains in speed and endurance.
The possible gains
from H.G.H. use are more varied and far less proven.
Auchus said that it
reduces body fat and increases lean muscle mass, which are desirable not just
for body building, where growth hormone abuse is believed to be widespread, but
in a variety of other sports, including cycling, where leanness boosts results.
But, like everything, there is debate about the full extent of that effect.
Anecdotal evidence
suggests that some athletes use H.G.H. to increase muscle mass. But Auchus and
Rogol said that there was considerable research showing that such gains were
modest.
One key difficulty in
determining what an individual performance-enhancing drug brings to an athlete,
Rogol said, is that few people involved in doping use just a single treatment.
That opens up the potential for complex interactions, both beneficial and
harmful, between various drugs and treatment methods.
There is speculation
that growth hormone may be used in conjunction with platelet-rich plasma
injections to swiftly heal injured muscles and tendons. While Galea is a
leading proponent of platelet therapy, he said during an interview that he
never combined the technique with growth hormone.
But there is
considerable doubt about whether injecting H.G.H. directly into injured tissue
— with or without platelet therapy — actually achieves anything.
Growth hormone does
not act directly. Instead it prompts the body to produce insulin-like growth
factor 1, or I.G.F.-1, which then triggers growth.
The overwhelming
majority of I.G.F.-1 is produced by the liver and delivered through the blood
stream. Evidence shows, however, that growth hormone can prompt local I.G.F.-1
production in other cells of the body. Auchus said that it was not clear if
such local production was significant enough to accelerate healing.
Even platelet therapy,
widely practiced on injured tissue, is an unproven treatment marked by
uncertainties; it is however legal and not banned by the World Anti-Doping
Agency.
To create
platelet-rich plasma, a small amount of the patient’s blood is put in a centrifuge
to separate its red blood cells from the platelets that release proteins and
other particles involved in healing. A small amount of the substance is then
injected into the damaged area. The belief is that the high concentration of
platelets — 3 to 10 times that of normal blood — prompts the growth of new
soft-tissue or bone cells.
Scott A. Rodeo, an
orthopedic surgeon at the Hospital for Special Surgery in New York and a former
United States Olympic team physician, said that when it comes to platelet
therapy, “the underlying rationale makes sense but there’s very little
underlying research.”
Rodeo, who is also a
physician for the New York Giants, said that Galea was far from unique in
providing the treatment in North America.
“If you want to do P.R.P. today, there are many
places to do it, although it may have been different two years ago,” he said.
“But sometimes in sports, a name gets out and gets recycled among athletes.”
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