067-a DOES EPO WORKS? – part1

Part 1: edited article from cycling blog: Het is Koers

Of course EPO works; everyone will say that and especially the pro-cyclists who were active in the EPO era.  EPO, or erythropoietin, increases the number of red blood cells (erythrocytes), and thus the oxygen transport capacity of the blood. As a result, more oxygen is delivered to the muscles, improving performance substantially.

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Also, kidney specialists will look surprised at the questioner because the answer to that question was already answered many years ago. Someone who is asking such a question is certainly not aware of the positive effects of EPO. For kidney specialists EPO is a drug that has improved the quality of life of kidney patients in a spectacular way. It is unfortunate that such an important drug has become famous as a doping agent and thus has gained a negative image. So kidney specialists and hematologists do not doubt the positive effects of EPO for a second.

The question if EPO works is not so good. The question we want to answer is whether EPO works for elite athletes. Very little research has been done about the effects of EPO in elite athletes, and that is the problem in the discussion. But then you cannot say because there is little research done in elite athletes it is a proof EPO does not work.

Bram Brouwer (1947) is a skating and cycling trainer and Industrial and Organizational Psychologist. After finishing his study he did research on doping in cyclists. He used the lack of research into the effects of EPO on cyclists as an argument that the drug will have little or no effect. Also the fact that most EPO doping positive riders were found in the ‘middle of the peloton’ would advocate a small effect: if the mediocre riders use it and still are not performing better than the clean riders, the effect cannot be large, Brouwer said.  Brouwer in de Volkskrant in 2013: “And the assumption – more oxygen in the blood is faster cycling – is a myth. Then you can, as a recreational cyclist, ride as fast as your favorites. “

Comment Peter Janssen: all these arguments of Brouwer’s are so unscientific and stupid that a serious discussion is hardly possible. Despite of that he gets a lot of attention in the Dutch press.

A big fallacy. As if recreational cyclists train just as hard as professionals.  Brouwer admits that the average speed of the peloton has become higher, but has seen this increase since “the early eighties when EPO did not exist.”   He explains the domination by the Italian riders through better training methods of Conconi and Ferrari. Maybe he does not know that EPO already was produced in large quantities since 1983. And he also forgets Francesco Moser in 1984 in his improvement of the world hour record of Eddy Merckx. He was trained by the training method of Francesco Conconi, who made extensive use of blood transfusions.

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With this kind of arguments of Brouwer’s we cannot clear the case. Even with the obvious link between the performance of Marco Pantani and his high hematocrit values, we get just a little bit further. We will have to rely on scientific research at a high level. Although not performed in elite athletes, there is a wide range of literature available on the effects of EPO in athletes I show you two:

A study from Norway, in 2000, in which they looked at the effect of EPO on endurance cyclists. The study was double-blind and placebo-controlled, neither the athletes nor the researchers knew who received EPO or a placebo. After four weeks of EPO use the VO2max, a measure of fitness level, was increased from 63.6 to 68.1 (an improvement of 7%).

Highly readable is the site of Ross Tucker and Jonathan Dugas. (http://sportsscientists.com) both promoted South African exercise physiologists.  Like me they are convinced of the effect of erythropoietin on performance. They are not only scientists, but also experts on the subject as well. The number of relevant publications to the medical-scientific database PubMed on the name of Tucker is 37.

They cite another study, which appeared in 2007, in the European Journal of Applied Physiology. A group of 16 healthy amateur cyclists was split; eight riders were administered for 13 weeks with EPO. The remaining 8 received placebo injections. The maximum power in the EPO group after four weeks was 13% higher, while the ‘time to exhaustion’ improved by 54%, from 22 to more than 33 minutes, at 80% of maximum power.

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Main criticisms were that the study was not blind (the athletes knew whether they were receiving EPO or placebo) and that it was not about professional athletes, whose effects on the maximum power will probably be smaller.

On the other hand, a small extension of the ‘time to exhaustion’ can easily mean the difference in a long mountain stage. In this study the ‘time to exhaustion’ increased by  no  less than  54%, which is a huge improvement, and not a little but a substantial extension.

So, EPO works in patients, in healthy volunteers and in well-trained athletes. The opinions about the performance-enhancing effect at top riders differ. Never believe just anyone, but if you can choose between a work and organizational psychologist with not scientific arguments or an exercise physiologist with a scientific approach of the subject and has done extensive research. For me a downhill question that is easy to answer.