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To the Editor.—In the United States, more than 1 million elite and recreational athletes use performance-enhancing drugs for muscle building purposes.¹ These performance-enhancing drugs, such as anabolic-androgenic steroids, clenbuterol, erythropoietin, and -hydroxybutyrate, have potential health consequences. Complications from the predominantly illicit and unsupervised use of these compounds include liver damage, lipid abnormalities, and myocardial infarction.^1-2 Many performance-enhancing compounds are injected, placing users at risk for infection with human immunodeficiency virus, hepatitis B and hepatitis C viruses, and abscesses.² Recently, insulin has been used as a performance-enhancing drug by bodybuilders.^3-5

Twenty self-identified anabolic-androgenic steroid injectors, recruited from local gyms, were interviewed regarding their injection practices. Eighteen (90%) of the 20 anabolic steroid users were white and 2 (10%) of the 20 were Hispanic. Eighteen (90%) of the 20 had first used anabolic steroids before 22 years of age. Five (25%) of the 20 anabolic-androgenic steroid injectors reported insulin use to . . . [Full Text of this Article]

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