Ioulietta Erotokritou-Mulligan

The history of doping and growth hormone abuse in sport

The earliest records of doping in sport come from the Ancient Olympics games when athletes are reported to have taken figs to improve their performance. With the advent of modern pharmacology in the 19th century, many athletes began to experiment with cocktails of drugs to improve strength and overcome fatigue. As this practice was not illegal, there are good records of the lengths athletes would go to in order to win. Alongside the benefits, came the dangers and following several fatalities, a code to ban performance enhancing drugs was gradually developed. Growth hormone was first isolated from the human pituitary gland in the 1950s. Its anabolic effects were soon recognised and athletes had begun to abuse it by the early 1980s, at least a decade before it was used therapeutically by adult endocrinologists. A number of high profile athletes have admitted using growth hormone. Detection of its abuse has been challenging and the lack of an effective test has undoubtedly encouraged its abuse. Only now are methodologies being developed that should stem this tide.

The use of growth hormone (GH)‐dependent markers in the detection of GH abuse in sport: Physiological intra‐individual variation of IGF‐I, type 3 pro‐collagen (P‐III‐P) and the GH‐2000 detection score

Background  Growth Hormone is abused by athletes for its lipolytic and anabolic properties. Its use is prohibited by the World Anti‐Doping Agency. The GH‐2000 project developed a methodology to detect its abuse using the concentrations of two GH‐dependent biomarkers, IGF‐I and type 3 procollagen (P‐III‐P). The sensitivity of this method may be improved by considering intra‐individual variability.

Influence of ethnicity on IGF-I and procollagen III peptide (P-III-P) in elite athletes and its effect on the ability to detect GH abuse.

Context  A method based on the two GH dependent markers, IGF‐I and procollagen III peptide (P‐III‐P) has been proposed to detect exogenously administered GH. As previous studies involved predominantly white European elite athletes, it is necessary to validate the method in other ethnic groups.

The Effect of Sports Injury on Insulin-Like Growth Factor-I and Type 3 Procollagen: Implications for Detection of Growth Hormone Abuse in Athletes

CONTEXT A method to detect exogenously administered growth hormone (GH) based on the measurement of two GH-dependent markers, IGF-I and type 3 procollagen (P-III-P) has been proposed. Skeletal or soft tissue injury may alter these markers. Elevations in either of these proteins after injury might lead to a false accusation of doping with GH. OBJECTIVE The objective of the study was to assess the effect of musculoskeletal or soft tissue injury on IGF-I and P-III-P concentrations in amateur and elite athletes and assess the effect of injury on the proposed GH detection method. DESIGN This was a longitudinal observational study after sporting injury. SETTING The study was conducted at Southampton General Hospital and British Olympic Medical Centre. SUBJECTS Subjects included elite and amateur athletes after an injury. INTERVENTION Interventions included measurement of IGF-I and P-III-P and application of the GH-2000 discriminant function score up to 84 d after an injury as well as classification of injury by type and severity. OUTCOME MEASURES IGF-I and P-III-P concentration and ability to detect GH abuse in athletes without the risk of false accusation because of an injury were measured. RESULTS There was no change in IGF-I concentration after an injury. By contrast, P-III-P concentrations rose by 41.1 +/- 16.6%, reaching a peak around 14 d after an injury. The rise in P-III-P varied according to injury type and severity. This rise had a trivial effect on the GH-2000 discriminant function score, and no subject reached the threshold needed for a doping offense. CONCLUSIONS Although there was a rise in P-III-P after injury, this was insufficient to invalidate the GH-2000 detection method based on IGF-I and P-III-P concentrations.

The development of decision limits for the implementation of the GH-2000 detection methodology using current commercial insulin-like growth factor-I and amino-terminal pro-peptide of type III collagen assays

BACKGROUND The GH-2000 project developed a method for detecting GH misuse based on the measurement of insulin-like growth factor-I (IGF-I) and the amino-terminal pro-peptide of type III collagen (P-III-NP). The objective of this study was to develop decision limits for the GH-2000 score to detect GH misuse in elite athletes using two currently available commercial assays for each analyte. STUDY DESIGN SUBJECTS 404 male (mean age 23.9 yrs, range 12-37 yrs) and 94 female elite athletes (mean age 24.5 yrs, range 18-34 yrs) participated. Blood samples were collected according to World Anti-Doping Agency (WADA) guidelines at various sporting events including 238 samples collected as part of the UK Anti-Doping Testing Programme. Laboratory analysis: IGF-I was measured by Siemens Immulite IGF-I assay and Immunotech A15729 IGF-I IRMA. P-III-NP was measured by RIA-gnost P-III-P and the UniQ™ PIIINP RIA. STATISTICAL ANALYSIS The GH-2000 score decision limits were developed through the analysis of the elite athlete samples. RESULTS For males and females separately, the distributions of GH-2000 scores were consistent with Normal distributions. Using a specificity of 99.99% new decision limits were determined which included an allowance for uncertainty associated with calculations based on a finite sample size. One outlier was identified with results incompatible with normal physiology and tested positive with the current isoform GH test. CONCLUSIONS We have developed decision limits using currently available commercial assays to measure IGF-I and P-III-NP in elite athletes. This should allow the introduction of a test for GH misuse based on the measurement of these GH sensitive biomarkers.

The GH-2004 project: the response of IGF1 and type III pro-collagen to the administration of exogenous GH in non-Caucasian amateur athletes

CONTEXT The GH-2000 team proposed a method based on IGF1 and type III pro-collagen (P-III-P) to detect exogenously administered GH. As previous studies involved predominantly white European athletes, it is important to assess whether the response of these markers to recombinant human GH (rhGH) differs with ethnicity. OBJECTIVE To examine the response of serum IGF1 and P-III-P and GH-2000 score to rhGH in non-Caucasian amateur athletes. DESIGN Double-blind placebo-controlled rhGH administration study. SETTING Wellcome Trust Clinical Research Facility, Southampton General Hospital. SUBJECTS The study included 31 male and 14 female amateur athletes of different ethnicities. Intervention The subjects were assigned to treatment with placebo or 0.1 IU/kg per day (low dose) or 0.2 IU/kg per day (high dose) rhGH for 28 days. Blood was collected weekly during treatment and on days 35, 42 and 84 during the washout period. Serum IGF1 and P-III-P were measured, and GH-2000 score was calculated. RESULTS IGF1, P-III-P and GH-2000 score rose in response to both low- and high-dose GH in both men and women. When compared with the Caucasian volunteers of the previous GH-2000 study, mean baseline and placebo-treated P-III-P and GH-2000 score were lower in GH-2004 men and women. Post-GH, however, peak IGF1 or P-III-P did not differ between studies but the peak GH-2000 score was lower in GH-2004 men. There was no difference between studies in the maximal change in IGF1, P-III-P and GH-2000 score in response to GH in either gender. CONCLUSIONS These data do not support a significant ethnic effect on the peak or maximal response to rhGH.

Serum Insulin-Like Growth Factor-I and Pro-Collagen Type III N-Terminal Peptide in Adolescent Elite Athletes: Implications for the Detection of Growth Hormone Abuse in Sport

CONTEXT A method based on two GH-dependent markers, IGF-I and pro-collagen type III N-terminal peptide (P-III-P), has been devised to detect exogenously administered GH. Because previous studies on the detection of GH abuse involved predominantly adult athletes, the method must be validated in adolescent athletes. OBJECTIVE The aim of the study was to examine serum IGF-I and P-III-P concentrations in elite adolescent athletes and to determine whether the method developed in adults is appropriate to detect GH abuse in this population. DESIGN AND SETTING We conducted a cross-sectional observational study at national sporting organization training events. SUBJECTS A total of 157 (85 males, 72 females) elite athletes between 12 and 20 yr of age participated in the study. INTERVENTION Serum IGF-I and P-III-P were each measured by two commercially available immunoassays. GH-2000 discriminant function scores were calculated. RESULTS Both IGF-I and P-III-P rose to a peak during adolescence, which was earlier in girls than in boys. All GH-2000 scores lay below the proposed cutoff limit of 3.7 (although some scores were close to this value), indicating that none of these athletes would be accused of GH doping if the GH-2000 discriminant formulae were used. The results between the two immunoassays for IGF-I and P-III-P were closely aligned. CONCLUSIONS The GH-2000 score rises in early adolescence, reaches a peak in athletes aged 13-16 yr, and then falls. We have found no evidence that the proposed GH-2000 score developed in adults would lead to an unacceptable rate of false-positive results in adolescent athletes, but caution may be required around the time of peak growth velocity.

A determination of the pre-analytical storage conditions for insulin like growth factor-I and type III procollagen peptide.

OBJECTIVE IGF-I and type III procollagen (P-III-P) have been proposed as markers to detect GH abuse. This study aims to determine whether the pre-analytical storage temperature or delayed centrifugation affect the measured IGF-I and P-III-P concentrations. DESIGN Observational study. SETTING Wellcome Trust Clinical Research Facility, Southampton. SUBJECTS Nineteen healthy volunteers. INTERVENTION Blood was collected into bottles containing a clotting agent, lithium heparin or EDTA. One sample from each group was centrifuged and stored at -80 degrees C (control sample). The remaining samples from each group were stored as either serum or whole blood at 4 degrees C or room temperature for up to five days prior to storage at -80 degrees C. OUTCOME MEASURES IGF-I and P-III-P. RESULTS The storage temperature or timing of centrifugation did not appear to affect IGF-I concentration. In contrast, the measured P-III-P concentration rose by 6.5-7% per day in clotted and lithium heparin samples when stored as whole blood (p<0.006) or serum (6.2-6.5% per day) at room temperature (p<0.001). P-III-P did not change when the samples were stored at 4 degrees C. Although collection into EDTA inhibited the rise in P-III-P, the baseline measured values were significantly higher than in other media and spiking experiments demonstrated that EDTA exerted a significant matrix effect on the assay. CONCLUSION While the optimum collection method is immediate centrifugation and storage at -80 degrees C, it would seem acceptable to store serum or clotted blood samples at 4 degrees C, but not ambient temperature, for up to five days. It is incumbent on the anti-doping authorities to provide facilities to allow this.

The effects of a freeze-thaw cycle and pre-analytical storage temperature on the stability of insulin-like growth factor-I and pro-collagen type III N-terminal propeptide concentrations: Implications for the detection of growth hormone misuse in athletes

A method based on two serum biomarkers - insulin-like growth factor-I (IGF-I) and pro-collagen type III N-terminal propeptide (P-III-NP) - has been devised to detect growth hormone (GH) misuse. The aims of this study were to determine the stability of IGF-I and P-III-NP concentrations in serum stored at -20°C and to establish the effects of one freeze-thaw cycle. Blood was collected from 20 healthy volunteers. Serum aliquots were analyzed after storage for one day at 4°C and one day, one week, five weeks, and three months at -20°C. IGF-I and P-III-NP results were combined to calculate a GH-2000 discriminant function score for each volunteer. Inter-assay precision was determined by analysing one quality control sample at each time-point. A single freeze-thaw cycle, storage of serum at 4°C for one day and at -20°C for up to three months had no significant effect on IGF-I or P-III-NP concentration. Intra-sample variability for IGF-I was 6.8% (Immunotech assay) and 12.9% (DSL assay). Intra-sample variability for P-III-NP was 10.9% (Cisbio assay) and 13.7% (Orion assay). When IGF-I and P-III-NP results were combined, intra-sample variability of the GH-2000 score expressed as a standard deviation varied between 0.31 and 0.50 depending on the assay combination used. Variability in IGF-I and P--III-NP results of stored samples is largely determined by the characteristics of the assays. A single freeze-thaw cycle, storage of serum at 4°C for one day or at -20°C for up to 3 months does not result in a significant change in GH-2000 score.

Moving one step closer to catching the GH cheats: The GH-2004 experience

Growth hormone is abused by athletes for its anabolic and lipolytic properties. The detection of GH abuse is challenging because it is an endogenous hormone whose concentration varies widely in any one day. The GH-2000 project proposed a test based on the measurement of IGF-I and type III pro-collagen (P-III-P). When the results of the GH-2000 project were presented to an expert workshop, the method was supported but it was felt that several issues needed to be resolved before the method could be adopted. The first was a potential effect of ethnicity as most subjects in the GH-2000 were white Europeans and the second was a possible effect of injury as P-III-P is a marker of soft tissue turnover. The GH-2004 project was conceived to address these concerns. The GH-2004 project has shown that while there are minor differences in IGF-I and P-III-P between ethnicities, these are small and do not affect the performance of the test. Injury leads to a small rise in P-III-P but again this is not of sufficient magnitude to affect the performance of the test. The GH-2004 project has provided further support for the marker approach as a means of detecting GH abuse in athletes. As WADA have not developed their own immunoassays, however, further work is needed to validate newer commercial assays measuring IGF-I and P-III-P to establish reliable conversion factors to the original GH-2000 units to allow the published formulae to be used.