Additive effect of erythropoietin use on exercise-induced endothelial activation and hypercoagulability in athletes

Jules A.A.C. Heuberger, Jelle J. Posthuma, Dimitrios Ziagkos, Joris I. Rotmans, Johannes M.A. Daniels, Pim Gal, Frederik E. Stuurman, Henri M.H. Spronk, Hugo Ten Cate, Jacobus Burggraaf, Matthijs Moerland, Adam F. Cohen

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Purpose: Recombinant human erythropoietin (rHuEPO) is known to increase thrombotic risk in patients and might have similar effects in athletes abusing the drug. rHuEPO is prohibited by anti-doping legislation, but this risk has not been investigated thoroughly. This analysis was designed to evaluate whether rHuEPO impacts hemostatic profile and endothelial and platelet activation markers in trained subjects, and whether the combination with exercise affects exercise induced alterations. Methods: This double-blind, randomized, placebo-controlled trial enrolled healthy, trained male cyclists aged 18–50 years. Participants were randomly allocated (1:1) to receive subcutaneous injections of rHuEPO (epoetin-β; mean dose 6000 IU per week) or placebo (0.9% NaCl) for 8 weeks. Subjects performed five maximal exercise tests and a road race, coagulation and endothelial/platelet markers were measured at rest and directly after each exercise effort. Results: rHuEPO increased P-selectin (+ 7.8% (1.5–14.5), p = 0.02) and E-selectin (+ 8.6% (2.0–15.7), p = 0.01) levels at rest. Maximal exercise tests significantly influenced all measured coagulation and endothelial/platelet markers, and in the rHuEPO group maximal exercise tests led to 15.3% ((7.0–24.3%), p = 0.0004) higher E-selectin and 32.1% ((4.6–66.8%), p = 0.0207) higher Platelet factor 4 (PF4) levels compared to the placebo group. Conclusion: In conclusion, rHuEPO treatment resulted in elevated E- and P-selectin levels in trained cyclists, indicating enhanced endothelial activation and/or platelet reactivity. Exercise itself induces hypercoagulability, and the combination of rHuEPO and exercise increased E-selectin and PF4 levels more than either intervention alone. Based on this, exercise potentially increases thrombotic risk, a risk that might be enhanced in combination with rHuEPO use.

Original languageEnglish
Pages (from-to)1893-1904
Number of pages12
JournalEuropean journal of applied physiology
Issue number8
Early online date2020
Publication statusPublished - 1 Aug 2020


  • Coagulation
  • Endothelial activation
  • Erythropoietin
  • Exercise
  • Hemostasis

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