Official reprint from UpToDate®

www.uptodate.com ©2020 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Prescription and non-prescription medications permitted for

performance enhancement
Author: Diana Robinson, MBBS FACSEP
Section Editor: Peter Fricker, MBBS, FACSP
Deputy Editor: Jonathan Grayzel, MD, FAAEM

INTRODUCTION

Performance-enhancing drugs, supplements, and other substances have been used in a variety of
settings by both athletes and non-athletes for decades. Individuals take performance-enhancing
drugs and substances for a variety of reasons, which include improving athletic performance,
increasing alertness, and improving appearance. Although the focus of the news media is on
competitive athletes caught using banned hormonal agents (eg, androgens, growth hormones) [1],
many non-hormonal drugs and other substances for performance enhancement are used, some of
which are banned but others of which are permitted and freely available.

There has been a massive increase in the use of supplements among athletes over the past few
decades. Companies worldwide make a range of claims about the ergogenic benefit of many
supplements. However, evidence suggests that only a small number have demonstrable benefits for
athletes. It is unknown whether the common practice of combining supplements causes additive or
interactive benefits or harms. Importantly, throughout the world, quality control for these substances is
generally poor, and regulations pertaining to their manufacture and marketing are weak, making it
difficult for athletes to determine which supplements are safe, effective, and legal.

This topic will review some of the most common prescription and non-prescription medications that
are not banned by the World Anti-Doping Agency and are used by athletes for performance
enhancement. Banned performance-enhancing drugs, including hormonal agents, and other
unbanned supplements are discussed separately. (See "Prohibited non-hormonal performance-
enhancing drugs in sport" and "Use of androgens and other hormones by athletes" and "Nutritional
and non-medication supplements permitted for performance enhancement".)
PRESCRIPTION MEDICATIONS

Psychiatric and neurologic medications — Antidepressants, anxiolytics, antipsychotics, and

anticonvulsants can improve mood and decrease anxiety [2]. These medications are not prohibited by
the World Anti-Doping Agency (WADA), although some have suggested that such drugs may give
certain athletes an unfair advantage. We believe that, for athletes suffering from anxiety or
depression, appropriate therapy with such medications should help to restore energy and motivation,
allowing them to optimize their training, performance, and recovery; but these medications are
unlikely to provide benefit beyond the athlete's normal baseline function. The use and adverse effects
of specific psychiatric and anticonvulsant medications are discussed separately. (See "Serotonin-
norepinephrine reuptake inhibitors (SNRIs): Pharmacology, administration, and side effects" and
"Pharmacotherapy for generalized anxiety disorder in adults" and "Antiseizure drugs: Mechanism of
action, pharmacology, and adverse effects" and "First-generation antipsychotic medications:
Pharmacology, administration, and comparative side effects" and "Second-generation antipsychotic
medications: Pharmacology, administration, and side effects".)

Selective serotonin reuptake inhibitors (SSRIs)

SSRI are widely used to treat depression. While some have
postulated that by improving the emotional state of healthy athletes, SSRIs
SSRI might improve
performance, evidence supporting this assumption is lacking. A few small studies involving healthy
young men and trained male cyclists given fluoxetine reported no improvement in anaerobic power,
endurance, maximum oxygen consumption (VO2 max), or fatigue time when tested on cycle
ergometers [3,4]. There are reports of serotonergic medications increasing perceptions of fatigue,
both mentally and physically, among users, which would be detrimental to training and competing.
Limited studies of serotonin/norepinephrine reuptake inhibitors have shown no benefit to athletes [5].

To continue reading this article, you must log in. For more information or to purchase a
personal subscription, click below on the option that best describes you:

Medical Professional

Resident, Fellow or Student

Hospital or Institution

Group Practice

Patient or Caregiver

Literature review current through: Feb 2020. | This topic last updated: Feb 05, 2019.
The content on the UpToDate website is not intended nor recommended as a substitute for medical
advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified
health care professional regarding any medical questions or conditions. The use of UpToDate
content is governed by the UpToDate Terms of Use. ©2020 UpToDate, Inc. All rights reserved.

REFERENCES

1. Catlin DH, Murray TH. Performance-enhancing drugs, fair competition, and Olympic sport.
JAMA 1996; 276:231.

2. Kaufman KR. Anticonvulsants in sports: ethical considerations. Epilepsy Behav 2007; 10:268.

3. Parise G, Bosman MJ, Boecker DR, et al. Selective serotonin reuptake inhibitors: Their effect on
high-intensity exercise performance. Arch Phys Med Rehabil 2001; 82:867.

4. Meeusen R, Piacentini MF, Van Den Eynde S, et al. Exercise performance is not influenced by a
5-HT reuptake inhibitor. Int J Sports Med 2001; 22:329.

5. Piacentini MF, Meeusen R, Buyse L, et al. No effect of a noradrenergic reuptake inhibitor on

performance in trained cyclists. Med Sci Sports Exerc 2002; 34:1189.

6. Petróczi A, Naughton DP. Potentially fatal new trend in performance enhancement: a cautionary
note on nitrite. J Int Soc Sports Nutr 2010; 7:25.

7. Ghofrani HA, Reichenberger F, Kohstall MG, et al. Sildenafil increased exercise capacity during
hypoxia at low altitudes and at Mount Everest base camp: a randomized, double-blind, placebo-
controlled crossover trial. Ann Intern Med 2004; 141:169.

8. Wang P, Fedoruk MN, Rupert JL. Keeping pace with ACE: are ACE inhibitors and angiotensin II
type 1 receptor antagonists potential doping agents? Sports Med 2008; 38:1065.

9. Sanchis-Gomar F, Lippi G. Telmisartan as metabolic modulator: a new perspective in sports

doping? J Strength Cond Res 2012; 26:608.

10. Holgado D, Hopker J, Sanabria D, Zabala M. Analgesics and Sport Performance: Beyond the
Pain-Modulating Effects. PM R 2018; 10:72.

11. Alaranta A, Alaranta H, Heliövaara M, et al. Ample use of physician-prescribed medications in

Finnish elite athletes. Int J Sports Med 2006; 27:919.
12. Trappe TA, Carroll CC, Dickinson JM, et al. Influence of acetaminophen and ibuprofen on
skeletal muscle adaptations to resistance exercise in older adults. Am J Physiol Regul Integr
Comp Physiol 2011; 300:R655.

13. Krentz JR, Quest B, Farthing JP, et al. The effects of ibuprofen on muscle hypertrophy, strength,
and soreness during resistance training. Appl Physiol Nutr Metab 2008; 33:470.

14. World Anti-Doping Agency Health, Medical & Research Committee (HMRC): Meeting minutes,
August 29-30 2017.

15. Oliynyk S, Oh S. The pharmacology of actoprotectors: practical application for improvement of

mental and physical performance. Biomol Ther (Seoul) 2012; 20:446.

16. McNaughton LR, Siegler J, Midgley A. Ergogenic effects of sodium bicarbonate. Curr Sports
Med Rep 2008; 7:230.

17. Maughan RJ, Depiesse F, Geyer H, International Association of Athletics Federations. The use
of dietary supplements by athletes. J Sports Sci 2007; 25 Suppl 1:S103.

18. Carr AJ, Hopkins WG, Gore CJ. Effects of acute alkalosis and acidosis on performance: a meta-
analysis. Sports Med 2011; 41:801.

19. Burke LM. Practical considerations for bicarbonate loading and sports performance. Nestle Nutr
Inst Workshop Ser 2013; 75:15.

20. Peart DJ, Siegler JC, Vince RV. Practical recommendations for coaches and athletes: a meta-
analysis of sodium bicarbonate use for athletic performance. J Strength Cond Res 2012;
26:1975.

21. Burke LM. Practical Issues in Evidence-Based Use of Performance Supplements: Supplement
Interactions, Repeated Use and Individual Responses. Sports Med 2017; 47:79.

22. Mc Naughton L, Thompson D. Acute versus chronic sodium bicarbonate ingestion and
anaerobic work and power output. J Sports Med Phys Fitness 2001; 41:456.