Husaini Laboratory Rate List

[Ceola Roefaro]

As a sports cardiologist, it is imperative to be aware of appropriate treatment strategies that will not jeopardize an athlete's eligibility for competition. Specifically, knowledge of the World Anti-Doping Agency (WADA) medication list is paramount to the decision-making process, as well as ensuring that athletes are not taking performance-enhancing substances.

INTRODUCTION TO ANTI-DOPING POLICIES
Prior to 1998, there were no reliable anti-doping laboratory tests for erythropoietin (EPO), though at that time it was known to be a doping agent. A few days prior to the 1998 Tour De France, a crew member of a cycling team was arrested when customs officers found steroids and other doping paraphernalia in his car. This arrest unraveled a scandal that led to police raids, arrests, and protests. Most importantly, it led to the discovery of widespread illegal doping during the 1998 Tour De France.1 In response, the International Olympic Committee founded the World Anti-Doping Agency (WADA) in 1999 with the mission to govern performance enhancing medical procedures and drugs to maintain fairness for professional athletes. Each year WADA publishes an international "Prohibited List" which goes into effect on January first of that year.2 In the United States (US), the US Anti-Doping Agency (USADA) has similar policies to protect the integrity of sport in the US with near universal agreement between the two lists.

It is well known that hormones and anabolic steroids are prohibited in sports; however, many common cardiovascular medications are also on the WADA list. This document will focus on some of these cardiovascular medications, which happen to be frequently prescribed and are considered first line treatments in many conditions. Each league, such as the National Football League or National Basketball Association, sets its own rules and policies on enforcement and testing. The goal of WADA and USADA is to establish a standard that would apply to any team playing outside its league, such as teams playing internationally. Knowledge of the specific league rules is helpful, but more importantly, understanding which drugs are on the list and when the medications are restricted is essential when caring for athletes. The complete list can be found online.

Diuretics
Diuretics are prohibited in all sports, both during training and during competition. Sports in which competition is based on weight categories restrict use of diuretics because of their ability to artificially and temporarily lower plasma volumes; thus, placing an athlete in a different weight category could provide a competitive advantage. Diuretics are also universally banned because they can be used to rapidly reduce detection of some doping agents (e.g., anabolic steroids) prior to anti-doping testing. All diuretics including loop diuretics (furosemide, torsemide and bumetanide), thiazide diuretics, spironolactone, and vaptans are prohibited (Figure 1).3

Beta Blockers
Beta blockers reduce sympathetic effects, such as increases in heart rate and blood pressure, which often are heightened during athletic competition. WADA explicitly prohibits beta blockers in sports that are reliant on stability of the extremities, such as archery, racing, billiards, darts, golf, shooting and fishing.4 All beta-blockers, such as carvedilol, metoprolol, atenolol, and propranolol, are included on the list. Beta blockers are allowed in other sports, but not in competition, as described below.

Other Medications
Anabolic steroids, growth factors (e.g., insulin-like growth factor-1, platelet-derived growth factor), certain beta-2 agonists and other hormones (e.g., aromatase inhibitors, anti-estrogens) are always prohibited. Stimulants, opioids, cannabinoids, and glucocorticoids (including prednisone) are prohibited in competition. Clonidine, while listed as a stimulant but often used for hypertension, is an exception and not prohibited.

Timing Definitions
WADA also classifies these banned substances based on when they may be taken. The listed drug classes may have a period of acceptable use. They define "in-competition" prohibition as drugs banned in the period commencing just before midnight (at 11:59 p.m.) on the day before a competition until the end of the competition and the sample collection process. WADA defines substances prohibited "at all times" as substances that are prohibited both in-competition and out-of-competition. Beta blockers are prohibited in-competition while diuretics are always prohibited.

Sport Type
Certain drugs are only prohibited with certain sports. Beta blockers, for example, are prohibited in sports that require stability of extremities, but they can be used in other sports. If applicable, the sports in which certain drugs are prohibited are listed under each drug category.

MEDICAL TREATMENT WITHOUT COMPROMISING ELIGIBILITY
Going back to the case vignettes, with your knowledge of the WADA list and cardiovascular medications, your clinic today goes extraordinarily well. The 50-year-old triathlete is transitioned from hydrochlorothiazide to amlodipine and is appreciative that their dehydration during races should also improve. The 19-year-old soccer goalie would like to avoid invasive procedures and chooses a trial of low dose long-acting diltiazem. The 42-year-old golfer was not aware that his metoprolol was jeopardizing his eligibility and is transitioned to a long-acting nitrate for his stable angina. Finally, the 24-year-old football lineman is started on an angiotensin receptor blocker and scheduled for a sleep study.

SUMMARY
Professional athletes with cardiovascular conditions may require pharmacological treatment. Under the jurisdiction of professional athlete governing bodies, WADA and USADA, some common cardiac medications are prohibited. Familiarizing oneself with these prohibited medications is important for any medical professional caring for the competitive athlete.

The presence of poor quality antibiotics on the market has contributed to the antibiotics resistance and global threat to public health. Antibiotic resistance is now a global concern. One area to address this issue is by evaluating the quality of antibiotics accessible to the public. The purpose of this study was to test and compare (with corresponding pharmacopeia) the quality of common oral antibiotics available in the country of Belize with a view to providing base-line data on the testing of medications imported to the country for public consumption. The study focused only on level 2 field-based screening quality assurance on three Key Access Antibiotics from the World Health Organization (WHO) Model List of Essential Medicines.

Five brands of antibiotic tablets/capsules with denoted pharmacopeia imported into the country of Belize were tested for quality at The University of Belize pharmacy laboratory. A sample of 30 tablets/capsules each of the selected antibiotic brand were used for study. Visual inspection and weight variation were done for each sample while Monsanto type tablet hardness tester, Roche@Tablet Friability Test Apparatus (single drum), and Ajanta@ Tablet Disintegration Test Apparatus (double basket) were conducted on selected antibiotics. Results were recorded and compared with corresponding pharmacopoeia references.

Most of the samples collected passed performed tests. Only a few samples from both BP and USP antibiotics failed in visual inspection and weight variation tests. All antibiotics tested conformed to their corresponding pharmacopeia reference in terms of friability and disintegration time.

Most of the selected antibiotics passed performed tests when compared with their pharmacopeia. Only a few samples from both BP and USP antibiotics failed the tests conducted. There is need for regular quality assurance tests on all medications imported to Belize especially antibiotics.

Copyright: 2020 Husaini et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

The presence of poor quality antibiotics on the market has contributed in no small measure to the global antibiotics resistance and a threat to public health. Antibiotic resistance has become a global emergency that healthcare professionals are confronted with in recent years [1]. In the United States alone, at least 2 million individuals were reported to be affected by antibiotic resistant bacteria [2]. The Center for Disease Control (CDC) and prevention reported more than 23,000 deaths in the United States 2013 [3] and 33,000 deaths in Europe [4] as a result of antibiotic resistance. The threat of antibiotics resistance does not only apply to the western developed countries but also in developing countries where health care provision is a major challenge. In Thailand for instance, antibiotic resistance has accounted for more than 38,000 deaths [5]. Between 2000 and 2010 alone, a total increase of antibiotic consumption has been observed in 71 countries. This increase has skyrocketed up to 45% for last-resort antibiotics, whose usage is only reserved when other antibiotic treatments are no longer effective [6]. The increased consumption of antibiotics can only result in the increase risk for developing resistance.

Furthermore, poor quality of antibiotics available to the public may lead to the development of antibiotics resistance. The quality of a medication is affected by low drug potency, poor formulation and/or presence of impurities [13, 14]. Although there is limited data that link the quality of specific antibiotics to resistance in particular diseases, evidence shows that resistance develops when bacteria is being exposed to sub-therapeutic doses of antibiotics. This will contribute to treatment regimens appearing as ineffective resulting in stronger antibiotics being needlessly introduced which will further escalate the possibilities of resistance [1].

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