Blood Doping: Lance Armstrong and the USPS Pro Cycling Team

What is Blood Doping and How Were the Cyclists Involved?

Blood doping is the misuse of certain methods or substances to increase red blood cell mass. Adding red blood cells allows the body to transport more oxygen to muscles and increase the endurance and performance of an athlete.1 Evidence overwhelmingly argues that world-renowned cyclist Lance Armstrong not only participated in a sophisticated and deceptive doping program, but also pressured cycling teammates to participate in doping or face possible expulsion from the team. Armstrong admitted in an interview with Oprah Winfrey on January 17, 2013 that he used performance-enhancing drugs while conquering a record seven Tour de France championships. He said it was “not possible” to win without doping.

What Was the Evidence Against Armstrong?

The Reasoned Decision document released on October 10, 2012 by the U.S. Anti-Doping Agency (USADA) detailed the use of performance-enhancing drugs and techniques by the US Postal Service Pro Cycling (USPS) Team. These allegations claimed the doping was orchestrated by seven-time Tour de France winner Armstrong to “evade detection, to ensure its secrecy and ultimately gain an unfair competitive advantage through superior doping practices.” 2,3

The document made public by the USADA detailed sworn statements from 26 witnesses, including 15 cyclists with direct knowledge of doping activities within the USPS Team. Cyclists stepped forward to speak against the activities of the team and Armstrong, and in the process guaranteed their own suspensions and disqualifications from competition.2,3 Use of erythropoietin (EPO), corticosteroids, testosterone, and blood transfusions by the USPS team are detailed in the document. The eleven riders that came forward with information about the doping scheme included Frankie Andreu, Michael Barry, Tom Danielson, Tyler Hamilton, George Hincapie, Floyd Landis, Levi Leipheimer, Stephen Swart, Christian Vande Velde, Jonathan Vaughters and David Zabriskie.2

What Were the Consequences?

Armstrong refused to contest the USADA allegations that he utilized performance-enhancing drugs or was involved in doping, and denied the accusations. Because of his decision not to defend these claims, the USADA was then able to strip Armstrong of all athletic titles dating back to August of 1998, including his seven Tour de France victories, and imposed a lifetime ban on his participation in competitive sports. USPS team physicians Dr. Michele Ferrari and Dr. Garcia del Moral, and cycling team trainer Jose “Pepe” Marti also received lifetime bans. The USADA imposed these punishments based on what they deemed as “the most sophisticated doping program that the sport has ever seen”.2 In addition, the International Cycling Union did not appeal the USADA’s mandate, which relinquished the right to advance Armstrong’s case to the Court of Arbitration for Sport, the highest court for appeals. Armstrong’s name will be removed from his seven back-to-back Tour de France titles spanning from 1999 to 2005. The winner’s spot for those years will remain empty.

What Does the Future Hold For Lance Armstrong’s Livestrong Foundation?

In the continued weeks after the USADA investigation, Lance Armstrong himself resigned as chairman of the Livestrong cancer awareness charity he founded. Nike, Trek Bicycles, Giro, Anheuser-Busch and Radio Shack, among others, also severed sponsorship ties with Armstrong. However, many sponsors, including Nike stated that they are committed to continuing their support of cancer awareness with The Livestrong Foundation. At the time of Armstrong’s resignation, Livestrong had raised close to $500 million in support of cancer awareness, education and research.

As for Armstrong, he said in a statement that "my family and I have devoted our lives to the work of the foundation and that will not change. We plan to continue our service to the foundation and the cancer community. We will remain active advocates for cancer survivors and engaged supporters of the fight against cancer." The longer term effects of the doping scheme on the future of the Foundation, and indeed on the sustainability of Lance Armstrong as a respected member of the cancer-fighting community awaits to be seen.

Performance Enhancing Agents: Selected Substances, Methods and Side Effects*

Use of EPO, corticosteroids, testosterone, and blood transfusions are the banned agents or methods outlined in the USADA Reasoned Decision document for the USPS team. The combination of these substances can result in boosted oxygen levels, lessened pain, increased stamina, and prolonged endurance to garner an unfair competitive advantage. However, the risks due to doping exceed the chance of imposed sanctions - there is a distinct health disadvantage due to doping as serious side effects can result in bodily harm or even death.

Erythropoietin (EPO) - Erythropoietin, or EPO is injected subcutaneously or intravenously, and is listed as substance that is prohibited at all times, both in- and out-of-competition on the WADA and USADA List. EPO use is prohibited by the International Olympic Committee (IOC) as well as the National Collegiate Athletic Association (NCAA). EPO is a common agent used in doping schemes around the world. In the body, erythropoietin occurs naturally and is released from the kidneys to stimulate red blood cell production in the bone marrow. Epoetin alfa (Epogen, Procrit) is one form of recombinant erythropoietin that is often used to treat anemia in kidney dialysis patients. EPO increases red blood cell mass, which allows more oxygen to be transported to muscles; when used in doping it boosts athletic performance. Side effects of EPO can be serious - it can lead to thickened blood due to additional red blood cell mass and may increase the risk for heart disease, stroke, and brain or lung embolism. Laboratory urine and blood tests are available for detecting use of EPO in athletes.1

Corticosteroids - All glucocorticosteroids are prohibited in competition when administered by oral, intravenous, intramuscular or rectal routes as listed by WADA and USADA. Intra-articular injections may not be prohibited. Corticosteroids are not necessarily performance enhancing, but may lessen inflammation and pain. Common corticosteroids, such as cortisone, prednisone, or hydrocortisone appear on the list.4,5 Serious side effects that may occur with corticosteroids include adrenal insufficiency, immunosuppression (especially with long-term use), congestive heart failure, and peptic ulcers. Laboratory testing can detect the presence of corticosteroids.

Anabolic Steroids - Anabolic agents are prohibited at all times, both in- and out-of-competition and appear on both the WADA and USADA Prohibited Lists. Anabolic steroid use is prohibited by the IOC as well as the NCAA. Anabolic steroids include all synthetic derivatives of testosterone, both oral and injectable. In the U.S., they are classified as Schedule III controlled substances due to the possibility of serious adverse effects and abuse potential. Anabolic steroids are performance-enhancing agents and act by increasing lean muscle protein synthesis.6 Adverse side effects with anabolic steroids include lowered high density lipoprotein levels (“good cholesterol”), high blood pressure, gynecomastia (abnormal development of mammary glands in men causing breast enlargement), aggression, azospermia (absence of sperm in semen), and menstrual irregularities in women. Laboratory testing can detect the presence of anabolic steroids.

Human Growth Hormone (hGH) - Human growth hormone is prohibited at all times, both in- and out-of-competition and appears on both the WADA and USADA Prohibited Lists. hGH use is prohibited by the IOC and the NCAA. Human growth hormone is naturally produced by the pituitary gland in the brain. The normal role of hGH is to stimulate the liver to secrete insulin-like growth factor (IGF-1) which plays a role in muscle and bone growth. hGH is available as a prescription medication (somatropin), but hGH effects on performance remain controversial. A controlled study determined that hGH increases lean body mass but has no effect on strength or exercise capacity.7 Side effects of of hGH include soft tissue edema, arthralgia, and carpel tunnel syndrome.6 Examples of other serious side effects associated with hGH include intracranial hypertension, pancreatitis, hypothyroidism, and diabetes.

Blood Transfusions - Blood transfusions are prohibited at all times, both in- and out-of-competition and appear on both the WADA and USADA Prohibited Lists. Blood transfusions are prohibited by both the IOC and the NCAA. Blood transfusions are one method used by athletes to engage in blood doping. One’s own blood (autologous blood doping) is withdrawn and refrigerated or frozen for later use. Blood can also be taken from another person with the same blood type and transfused into the athlete (homologous blood doping). Transfusing blood increases oxygen delivery to tissues and can improve performance, especially in distance sports such as cycling. The reemergence of blood transfusions for doping is most likely due to the availability of tests for EPO detection. Blood transfusions can have serious risks. Homologous transfusions can result in transmission of viruses, such as HIV or hepatitis, or other bloodborne diseases. There is also risk due to improper procedure or sterility of equipment. As with erythropoietin, cardiovascular dangers  such as deep vein thrombosis, pulmonary embolism, and coronary and cerebral thrombosis may occur due to high levels of red blood cells. Laboratory tests for homologous blood transfusion exist, but it is difficult to detect autologous blood transfusions. The Athlete Passport is developed to help in the detection of transfusions. The Passport is based on following an athlete’s biological profile to detect changes over time, such as high hemoglobin levels, and is added to other more traditional anti-doping tests.1,8

Diuretics - Diuretics are prohibited at all times, both in- and out-of-competition. Diuretics appear on both the WADA and USADA Prohibited Lists, and are prohibited from use by the IOC and the NCAA. Diuretics are normally used in medicine to treat hypertension and fluid retention. Diuretics, a type of masking agent, increase urine and sodium excretion from the kidneys. A strong diuretic can increase urine flow up to 1.5 gallons (6 liters) per day. Diuretics are taken to hide or "mask" the presence of prohibited drugs that may be screened for in athletic competition. Diuretics increase urine flow and lead to the dilution of urine, which lowers the concentration and detectability of the drug in the urine. Diuretics may also be used to aid in rapid weight loss due to water excretion.10 Examples of common diuretics include hydrochlorothiazide, furosemide, triamterene, acetazolamide and amiloride. If an athlete is using any quantity of a substance subject to threshold limits (i.e. formoterol, albuterol, salmeterol, morphine, cathine, ephedrine, methylephedrine and pseudoephedrine) in conjunction with a diuretic or other masking agent, a Therapeutic Use Exemption (TUE) is required for both agents.5 A TUE allows an athlete to take an otherwise prohibited drug if it is deemed medically necessary. Serious side effects that may occur with diuretic use include altered potassium levels, abnormal heart rhythms, jaundice, pancreatitis, and life-threatening allergic reactions. Diuretics are detectable by laboratory analysis of a urine or blood sample.

Ephedrine/Pseudoephedrine - Pseudoephedrine is prohibited in competition when the urinary concentration exceeds 150 microgram (mcg)/mL, and ephedrine is prohibited in competition when concentrations exceed 10 mcg/mL. Their use is not prohibited out of competition. Both substances appear on the WADA and USADA Prohibited Lists, and are prohibited from use by the IOC and the NCAA. These thresholds concentrations are not valid in the presence of diuretics due to the masking effect of the diuretic. If an athlete is using a diuretic they must have a Therapeutic Use Exemption (TUE) for both the diuretic and ephedrine/pseudoephedrine. Pseudoephedrine and ephedrine are classified as stimulants, but data is controversial as to their effects on athletic performance. Crossover studies have failed to show an improvement in fatigue or prolonged cycling performance.10 Serious side effects involve the cardiac and central nervous system including heart palpitations, insomnia and psychiatric symptoms such as anxiety or irritability. Heart attacks and death, strokes, seizures, and psychosis have also been rarely reported.6 Ephedrine or pseudoephedrine are detectable by laboratory analysis of a urine or blood sample.

*Note: This list is not comprehensive. Review the WADA and USADA Prohibited Lists and/or consult with your specific institution for the most complete and up-to-date list of prohibited substances and/or methods.

More Resources:

See Also:

References:

  1. The World Anti-Doping Agency Website. Science and Medicine - Q&A on Blood Doping. Accessed October 17, 2012.
    http://www.wada-ama.org/en/Science-Medicine/Science-topics/QA-on-Blood-Doping/
  2. United States Anti-Doping Agency (USADA). U.S. Postal Service Pro Cycling Team Investigation. Statement from USADA CEO Travis T. Tygart Regarding the U.S. Postal Service Pro Cycling Team Doping Conspiracy. Accessed October 18, 2012. http://cyclinginvestigation.usada.org/
  3. United States Anti-Doping Agency (USADA). U.S. Postal Service Pro Cycling Team Investigation. Reasoned Decision. Accessed October 19, 2012. http://d3epuodzu3wuis.cloudfront.net/ReasonedDecision.pdf
  4. United States Global Drug Reference Online. Drug Search. Accessed October 18, 2012. http://www.globaldro.com/us-en/search/search.aspx
  5. The World Anti-Doping Agency Website. 2012 List of Prohibited Substances and Methods. Accessed October 21, 2012. http://list.wada-ama.org/
  6. Jenkinson DM, Harbert AJ. Supplements and Sports. American Family Physician. 2008;78:1039-46. Accessed October 21, 2012. http://www.aafp.org/afp/2008/1101/p1039.html
  7. Liu H, Bravata DM, Olkin I, et al. Systematic review: the effects of growth hormone on athletic performance. Ann Intern Med. 2008;148:747-58.
  8. The World Anti-Doping Agency Website. Science and Medicine - Q&A on Blood Doping. Accessed October 17, 2012. http://www.wada-ama.org/en/Science-Medicine/Athlete-Biological-Passport/Q--A-on-the-Athlete-Biological-Passport/
  9. Cadwallader AB, de la Torre X, Tieri A, et al. The abuse of diuretics as performance-enhancing drugs and masking agents in sport doping: pharmacology, toxicology and analysis. British Journal of Pharmacology 2010;161:1-16. Accessed October 18, 2012. http://www.ncbi.nlm.nih.gov/pmc/articles/pmc2962812/
  10. Chu KS, Doherty TJ, Parise G, et al. A moderate dose of pseudoephedrine does not alter muscle contraction strength or anaerobic power. Clin J Sport Med. 2002;12:387-90.

Last updated: 2013-04-11 by Leigh Anderson, PharmD.

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