Erythropoietin as a performance-enhancing drug: Its mechanistic basis, detection, and potential adverse effects

Mol Cell Endocrinol. 2018 Mar 15:464:75-87. doi: 10.1016/j.mce.2017.01.033. Epub 2017 Jan 22.


Erythropoietin (EPO) is the main hormone regulating red blood cell (RBC) production. The large-scale production of a recombinant human erythropoietin (rHuEPO) by biotechnological methods has made possible its widespread therapeutic use as well as its misuse in sports. Since the marketing of the first epoetin in 1989, the development has progressed to the third-generation analogs. However, the production of rHuEPO is costly, and the frequent administration of an injectable formula is not optimal for compliance of therapeutic patients. Hence, pharmaceutical industries are currently developing alternative approaches to stimulate erythropoiesis, which might offer new candidates for doping purposes. The hypoxia inducible factors (HIF) pathway is of particular interest. The introduction of new erythropoiesis-stimulating agents (ESAs) for clinical use requires subsequent development of anti-doping methods for detecting the abuse of these substances. The detection of ESAs is based on two different approaches, namely, the direct detection of exogenous substances and the indirect detection, for which the effects of the substances on specific biomarkers are monitored. Omics technologies, such as ironomics or transcriptomics, are useful for the development of new promising biomarkers for the detection of ESAs. Finally, the illicit use of ESAs associates with multiple health risks that can be irreversible, and an essential facet of anti-doping work is to educate athletes of these risks. The aim of this review is to provide an overview of the evolution of ESAs, the research and implementation of the available detection methods, and the side effects associated with the misuse of ESAs.

Keywords: Athlete biological passport; Biomarkers; Doping detection; Erythropoietin; Omics technologies.

Publication types

  • Research Support, Non-U.S. Gov't
  • Review

MeSH terms

  • Doping in Sports
  • Erythropoietin / adverse effects*
  • Erythropoietin / analysis*
  • Erythropoietin / pharmacology
  • Humans
  • Performance-Enhancing Substances / adverse effects*
  • Performance-Enhancing Substances / analysis*
  • Performance-Enhancing Substances / pharmacology
  • Transcriptome / genetics


  • Performance-Enhancing Substances
  • Erythropoietin