Microsoft word - english_uiaa medcom rec no 22a drug misuse 2014 v1-1.doc



THE INTERNATIONAL MOUNTAINEERING AND CLIMBING FEDERATION
UNION INTERNATIONALE DES ASSOCIATIONS D'ALPINISME
Office: Monbijoustrasse 61 y Postfach
CH-3000 Berne 23 y SWITZERLAND
Tel.: +41 (0)31 3701828 y Fax: +41 (0)31 3701838
e-mail: office@uiaa.ch
OFFICIAL STANDARDS
UIAA MEDICAL COMMISSION
Drug use and Misuse in Mountain-
Intended for mountaineers and medical lay persons (version for professionals see Vol.22b, in preparation) D. Hillebrandt, T. Küpper, E. Donegani, U. Hefti, J. Milledge, V.
Schöffl, N. Dikic, J. Arnold, G. Dubowitz
UIAA MedCom Standard No.22a: Drugs in Mountaineering (lay version) Preamble
It is not the UIAA Medcom's intention to judge.
We simply welcome openness and honesty but
also want to protect mountaineers from possi-
ble harm. We do believe that, wherever possi-
ble, the use of drugs specifically taken with the
intention to enhance performance should be
avoided in the mountains.

Content
1 Introduction . 3
2 Drugs . 4
2.1 Acetazolamide (Diamox) . 5 2.2 Alcohol. 5 2.3 Ammonium Chloride. 6 2.4 Amphetamines other stimulants. 6 2.5 Anabolic Drugs. 6 2.6 Anti-epileptic drugs/Anti-migraine drugs . 6 2.7 Aspirin . 7 2.8 Beta 2.9 Coca . 7 2.10 Dexamethasone . 7 2.11 Erythropoietin blood doping and haemodilution. 8 2.12 Ginkgo Biloba. 8 2.13 Ibuprofen . 8 2.14 Inhaled weight Heparins . 9 2.16 Nifedipine . 9 2.17 Dietary Nitrate (Beetroot Juice). 9 2.18 Opiates . 9 2.19 Oxygen . 10 2.20 Progesterone. 10 2.21 Phosphodiesterase type-5 inhibitors eg sildenafil (Viagra), tadalafil (Cialis). 11 2.22 Psychotropic Drugs . 11 2.23 Rhodiola crenulata . 11 2.24 Salmeterol . 11 2.25 Sleep 2.26 Theophylline. 12 3 References. 13 Members of UIAA MedCom (in alphabetical order). 16 History of this recommendation paper. 16 UIAA MedCom Standard No.22a: Drugs in Mountaineering (lay version) 1 Introduction
Since man has ascended mountains most people have looked for the easiest way to achieve their
desired summit. As the "sport" of mountaineering has evolved and developed some people have
striven for more challenging lines, more extreme altitude or more technically difficult climbs but it has
to be appreciated that mountaineering "rules" are artificial and imposed by humans. Different special-
ised aspects of mountaineering have evolved. Some people enjoy solo ascents of challenging lines on
Himalayan giants, others ski mountaineering, trekking, mountain running, frozen waterfalls, sport
climbing or bouldering in wooded meadows. Some of these disciplines are formally competitive and
need rules to maintain integrity. In this specialised field we leave the World Anti Doping Agency
(WADA) to devise enforceable doping regulations and tests. A regularly updated list of their regulated
substances can be found on their website (1).
Non WADA regulated individuals have to determine their own personal standards for enjoyment, chal-lenge and acceptable risk on whatever route they choose. No system of drug testing could ever, or should ever, be policed for recreational climbers. Sponsored climbers or those who climb for status need to carefully consider both the medical and ethical implications if using drugs to aid performance. In some countries (e.g. Switzerland and Germany) administrative systems for mountaineering or medication control dictate a specific stance, but for most people any "rules" would be unenforceable and have to be a personal decision. The underlying principle must be honesty with oneself and hon-esty with one's peers. This applies to the use of physical aids such as fixed ropes, bolts or top rope practice of a climb, It applies to transport aid such as porters, aircraft or boats on an approach or de-scent. It also applies to pharmacological aids. Just as one would be expected to declare points of aid (bolt or peg) on a rock climb so one should be prepared to declare the use of pharmacological aids. This has been accepted for years with Habler and Messner being singled out for praise for the first ascent of Everest without artificial oxygen. This in no way detracted from the first ascent by Hillary and Tensing who chose to use well designed oxygen apparatus based on the current cutting edge tech-nology, and a bit of improvisation. At this time others were acknowledging the use of performance enhancing drugs in the mountains. Hermann Buhl on Nanga Parbat in 1953 used Pervitin (metham-phetamine) on the ascent after a fight with his own ethical conscience (2). In doing this he was follow-ing the practice of amphetamine use by military personnel of several countries in the Second World War and which is still continued by some countries to this day. Different cultures and different generations have different attitudes. This diversity and lack of informed information frequently comes to a head on Everest where one is dealing with the most extreme alti-tude combined with climbers with many differing motivating factors. To quote Dr Luanne Freer who has offered a base camp medical service on Everest since 2003 "We estimate that during our informal survey on Everest spring 2012, at least two thirds of climbers we contacted were prescribed several performance enhancing drugs (PEDs) and had intent to use them not for rescue, but to increase their chances of summit success. When a commercial guide of a large expedition asked our staff to counsel their team on use of PEDs for summit day, we were alarmed to find a tent full of anxious climbers with pockets full of prescription drugs (prescribed by their personal physicians and filled at home pharma-cies) and with no understanding or instructions on when and how to use them. Who are the health care providers writing these prescriptions? We have a duty to provide education and specific instruc-tions about how and when these potentially dangerous drugs should be used. We have treated sev-eral climbers over the years, who without good advice, ingested every single drug in their arsenal and lost their chances to summit because of symptoms related to polypharmacy. No matter where we sit on either side of this issue, it is our duty as health care prescribers to provide very clear instructions to our patients about how, when, why to use any drug we prescribe. If we aren't certain what doses or prescribing regimen are best for performance enhancement, then we shouldn't prescribe them for that purpose (or we should educate ourselves before doing so.) Let's encourage our colleagues to do the same." The generation of British climbers attempting major new routes on Himalayan peaks in the late 1970s and 80s strove to avoid any drug use on the mountain, including oxygen (3). It was however admitted that some might have considered using drugs had they been aware of their existence! It is not the UIAA Medcom's intention to judge. We simply welcome openness and honesty but also want to protect mountaineers from possible harm. We believe that, wherever possible, the use of po-tentially performance enhancing drugs should be avoided in the mountains. Having said that we are aware of the many sides of the debate which were outlined in the editorial and following invited com- UIAA MedCom Standard No.22a: Drugs in Mountaineering (lay version) mentaries and subsequent letters in Wilderness and Environmental Medicine (4) and also in the article by Devon O'Neil on " Climbing's Little Helper" (5). As physicians who love the mountains we are aware of the desire for rapid ascent but are also in-creasingly aware of the potential for harm, especially when poorly proven potentially potent drugs are used at altitude (6). The more drugs that are used by mountaineers the greater the chance for phar-macological interactions with consequent dangerous side effects. The first identified attempt to look at the pros and cons of specific drug use at altitude was published in July 2000 (7) and a paper was pre-sented on the subject at the Congress of the International Society of Mountain Medicine in Barcelona by Berghold in 2002 which provided the original idea for this paper (8). We are aware that some com-mercial expedition and trekking companies positively encourage the use of drugs by their clients. Ulti-mately this has to be to increase profits in preference to encouraging slow, sensible acclimatisation. We suggest clients think carefully before accepting this practice. We accept that there may be time when the use of drugs can be appropriate but this should be tailored to the individual patient or spe-cific circumstances, such as a strong previous history of altitude illness or a rescue party going high in an emergency. For the business man or scientist going to altitude to work mountaineering ethics may not be relevant. Furthermore, one could have an eternal debate on the philosophical and ethical as-pects of drug use on religious pilgrimages to high altitude shrines and festivals. Whatever the ultimate personal decision it is preferable that any advice should come from an experi-
enced mountain medicine doctor who will also be able to advise on sensible ascent profiles and man-
agement of acute problems in the field. The impression gained at Everest Base Camp is that many
climbers are prescribed drugs by doctors with no mountain medicine experience. The dilemma for
prescribing physicians is well illustrated in the case study outlined by Bärtsch and Swenson in the New
England Journal of Medicine (9). Anonymous internet advice and drug supply via the internet or from
a dubious unregulated pharmacy should be avoided and can be very dangerous.
Physicians advising youngsters should consider asking their parents how they feel about the principle of encouraging children to use drugs to aid sport performance or recreation which is in direct contra-vention of the ethical principles of the international Olympic movement. In this paper we will look at the pharmaceutical agents that are or have been used in the mountains of the world. We will look at the pros and cons, side effects and benefits, possible interactions, risks, and at the research evidence currently available for each drug. We hope to update this every few years as evidence changes. Each mountaineer, climber or trekker must make his own personal decisions whether acting as a professional or recreational mountaineer or as a commercial expedition client. In the final analysis be honest with yourself and with the international mountain community. 2 Drugs
Some authorities differentiate between drugs that enhance performance and those that change per-
formance. An example of the former would be acetazolamide and an example of the latter would be
cannabis. Some people also differentiate between conventional medical drugs, dietary supplements
and herbal medication. In this advice paper we will not differentiate but it must be accepted that evi-
dence from reputable peer reviewed journals may be absent in some cases. We accept that many of
these drugs have a very valuable role to play in the treatment of potentially life threatening altitude and
other illness and in this situation we have no hesitation in supporting their use often buying vital time
for descent.
Interestingly, in the 2010 guidelines on the prevention and treatment of acute altitude illness pub-lished by the USA based Wilderness Medical Society (10) every section on prevention initially stresses slow ascent and every section on treatment initially stresses descent. Many readers seem to miss these vital points and skip straight onto the pharmacological sections in their rush to read the paper. They then rush to the pharmacy as part of their rush to "conquer" their mountain. It should be noted that most research into drugs used at altitude is done at 5000m or below. There are very few research studies of quality done above this height. We have no way of knowing if the side effect profile of the same drugs used at higher altitude will be the same. Extrapolation of any scientific data is unsound and potentially dangerous. The limited data available on drug use in mountaineers shows that the use of acetazolamide in Nepal rose from 1% in 1986 to 12% in 1998 to 25% in 2010 (11 & 12). UIAA MedCom Standard No.22a: Drugs in Mountaineering (lay version) In a pilot study 38.9% of trekkers in the Khumbu used drugs "for acclimatization" (13). An older study from 1993 reported that a total of 9.8% of recreational mountaineers in the European Alps tested posi-tive for amphetamine, with 2.7% positive at altitude of 2,500 to 3,300m and 7.1% positive above 3,300m (14). Since tests were not performed for other drugs the total percentage of mountaineers who used drugs to increase performance may have been significantly higher. According to observations undertaken trekking or mountaineering at the Bafaru Bivouac (4,860m) on Mt. Kilimanjaro 46.7% of those studied took acetazolamide, 40,0% dexamethasone, 4.5% coca leaves, and only 8.8% were "clean". In most cases this use was based on peer advice and pressure rather than any medical indi-cation. Despite this drug consumption 80.0% suffered from AMS, 2.2% (n=1) from HAPE and 2.2% (n=1) from high altitude cerebral oedema (HACE) (15). Data from other groups shows a similar in-creasing pattern. In one study 28% of rock climbers reported climbing under the influence of drugs or alcohol and these climbers documented more injuries (p<0.008) compared to those who climbed "clean" . Males admit-ted more illicit substance use (p>0.001) compared to women. (16). Some climbing athletes have had positive drug tests by WADA. 2.1 Acetazolamide (Diamox)
To quote from one of the most respected high altitude medical textbooks "Acetazolamide remains the
mainstay of pharmacologic prophylaxis against AMS" (17). Despite it being used for many years no-
body is exactly sure how this mild diuretic carbonic anhydrase inhibitor works in AMS prevention. Its
current primary medical use is for the treatment of refractory glaucoma. This group of drugs were first
investigated for AMS prevention in 1965 (18). There are many theories about its mechanism of action
and it certainly has a multifactorial effect on acclimatisation (19). Initially it was used in the same
doses required in some cases of glaucoma but over the years studies have shown that lower doses
work just as well such that a dose of 125mg twice a day, ideally started 24 hours prior to ascent, is
now recommended (20).
Despite a large amount of evidence for its use in AMS it is not licensed for this so in some countries some doctors are reluctant to prescribe it. It is off patent so it is never likely to be economic for it to become licensed. In some countries it is freely available in pharmacies. In the past it was thought it might mask the symptoms of AMS making the user more at risk of HAPE or HACE but it is now thought that it "kick starts" the acclimatisation process (21). PROS: It works and for most people has negligible side effects compared with some other drugs in
this article.
CONS: It is a diuretic so users may become slightly dehydrated especially when undertaking unaccus-
tomed exercise and the use of a pee bottle may become essential to avoid trips outside on a cold
night at altitude. Its use should be avoided in patients who have decreased renal function at sea level.
It can cause tingling of fingers and toes in some susceptible subjects and can make fizzy drinks taste
flat. It is sulphonamide related so anybody who has a sulphonamide allergy or sensitivity should avoid
its use although this is rare. Medical research on its action has only been undertaken to a maximum
altitude of 5895m (22) so its use above this altitude is based on the assumption that it may continue to
work at higher altitudes. The scientific jury is out on its use at extreme altitude.
INTERACTIONS: If taken with corticosteroids or theophyllines it can lower the blood potassium level
(hypokalaemia). The commonly used diabetes drug metformin causes a degree of lactic acidosis as
does acetazolamide. Used together this effect is increased which might, in some cases, cause major
problems.
ETHICS: This is a personal decision. It is currently WADA banned due to its diuretic action rather than
its acclimatisation effect.
2.2 Alcohol
Alcohol is used, abused and enjoyed by mountaineers throughout the world.
PROS: It can be a very social drink and in the form of whisky is one of the few ways that the true spirit
of the mountains can be obtained in a bottle.
UIAA MedCom Standard No.22a: Drugs in Mountaineering (lay version)
CONS: In even slight overdose it can mimic AMS or HACE. It also reduces reflex times, can interfere
with physical balance and also impairs the ability to assess and manage risk. Its slow degradation in
the body (0.12% per hour) means that these effects will persist if undertaking an early Alpine start to
climb.
2.3 Ammonium Chloride
Included only for historical interest but based on some good theoretical science on acclimatisation in
the early 1930s. It alters the acidity of the blood.
Raymond Greene based his pressure chamber research and his work on the 1933 Everest expedition on observations he made on Kamet in 1931 and Ruttledge made on Nanda Devi in 1932. He even predicted the use of high altitude laboratories for future research (23). 2.4 Amphetamines and other stimulants
Stimulant drug use has a long history: Anecdotal accounts suggest that many ascents of 8000m-
peaks in the 50's were done with the use of drugs, mostly amphetamines.
In the UK in 1978 the Climbers Club journal published Jim Perrin's account of a solo ascent of the steep Coronation Street rock climb in the Cheddar Gorge using a combination of speed (ampheta-mine) and Cocaine. The article " Street Illegal" became a cult short story and a collector's piece. CONS: There is a very real risk of overexertion if using these stimulants resulting in exhaustion, hypo-
thermia, collapse and death.
Since the early Everest attempts some climbers have praised the use of Caffeine. Houston's account of the grief reaction of the British team members on Nanda Devi in 1936 when the tea container was dropped and lost may reflect on this drug dependency. The use of caffeine was discussed by Peter Hackett when he stressed that "Importantly, habitual caffeine users should not discontinue caffeine because of travel to altitude; the symptoms of withdrawal are very similar to AMS and can be misdiag-nosed as AMS". He also postulated that its effects on ventilation, cerebral circulation and as a psy-chostimulant may be beneficial and merit further study (24). 2.5 Anabolic Drugs
Anabolic drugs may have been used in the preparation for expeditions and hard rock climbs. The main
area of their use is in sport climbing where much training is done in Gyms and fitness centres (25)
where they are easily available and primarily used for muscle regeneration after severe training.
CONS: Their multiple side effects include depression, hallucinations, aggression and hypertension. These side effects may be even more pronounced at altitude and may interfere with the diagnosis of HACE. Physicians, guides and coaches should be aware of this potential problem. 2.6 Anti-epileptic drugs/Anti-migraine drugs
Gabapentin which is normally used as a drug to control epilepsy, neuropathic pain and as an unli-
censed drug for migraine control (26). It has also been studied for treatment of the altitude headache
associated with AMS (27). The paper only looked at 24 subjects at 3500m and its action may only
have been on High Altitude headache. One look at the drug's side effect profile would put most climb-
ers off considering its use.
CONS: Possible drowsiness, dizziness, vertigo, nausea, vomiting, cough, flatulence and more. Not
been studied for prevention.
Sumatripan is a 5HT1 receptor agonist which is used to treat migraine. It has been studied for the prevention of AMS (28 & 29). The second study was of 102 subjects at only 3500m and again poten-tial side effects are more pronounced than low dose acetazolamide. Further work has not been under-taken. UIAA MedCom Standard No.22a: Drugs in Mountaineering (lay version) 2.7 Aspirin
Aspirin is a COX-inhibitor with non-steroidal anti-inflammatory action which has been studied for the
control of high altitude headache in doses of 320mg four hourly (30). It is likely that its primary effect
my simply be on headache control rather than true prevention of AMS.
CONS: Although easily available without prescription in many pharmacies around the world the ad-
verse effects of Aspirin should not be underestimated. Its antiplatelet effect increases the risk of inter-
nal bleeding from the stomach and gut, brain, retina and respiratory system. It can cause indigestion
and effect kidney function.
Some mountaineers use Aspirin on the grounds it reduces clotting of the thicker blood at altitude pos-sibly helping to prevent a potential stroke, venous or pulmonary thrombosis. This possible benefit is very small (if at all) and has to be weighed up against the risk of gastrointestinal haemorrhage which would be further increased if combined with dexamethasone. 2.8 Beta blockers
Betablockers such as propanolol and atenolol have been used to reduce the physical symptoms of
stress and anxiety and for this reason they might be considered by sports climbers. They have cer-
tainly been used in competitive events such as rifle target shooting and darts in the past. They may
also be used for pre existing blood pressure control in patients going to high altitude (31).
CONS: Beta blockers reduce the maximum pulse rate and therefore maximal workload, can cause
lethargy and decrease the circulation to the extremities potentially putting he person more at risk of
frostbite.
2.9 Coca
Despite the popularity of Coca in South America to prevent AMS either as chewed leaves or as the
infusion "mate de coca" there is no evidence of it working in any clinical trails (32).
2.10 Dexamethasone
This steroid drug is being increasingly used at altitude and this reflects the layperson's desire for a
medical fix for the natural process of acclimatisation without an appreciation of the medical risk/benefit
ratio.
Unlike acetazolamide it does not improve acclimatisation or affect ventilation but minimises the symp-toms of altitude headache, one component of AMS. It is a very valuable drug for the treatment of HACE and can be used to buy time whilst preparing for descent in the treatment of life threatening altitude illness. It has been studied for prevention of AMS and if used for this the patient has already used the one potentially lifesaving drug should they later develop HACE. PROS: At a dose of about 8mg daily in divided doses it has been shown to reduce the symptoms of
AMS. THIS DOSE SHOULD NOT BE TAKEN FOR MORE THAN ABOUT 7 DAYS (33 & 34).
CONS: As with any powerful potentially lifesaving medication it comes with marked side effects and
dangers. Since it does not actually facilitate acclimatisation the patient must be monitored carefully for
symptoms of AMS or HACE especially if it is stopped abruptly when at altitude. This drug should not
be used in children or pregnant women (except for life saving emergency treatment). Side effects in-
clude an Addisonian crisis if stopped abruptly after more than a few days, Cushing's syndrome if high
does are taken for a long time, mood changes, depression, hyperglycaemia, peptic ulcer, gastric
haemorrhage and indigestion to name but a few (6). Corticosteroid induced euphoria can decrease the
ability to assess and manage risk in the mountains.
Although recommended as the second line pharmacological agent for AMS prevention by the U.S.A based Wilderness Medicine Society (35) it should be noted that they recognise the potential risks and UIAA MedCom Standard No.22a: Drugs in Mountaineering (lay version) state that slow sensible acclimatisation should be the first line of preventative behaviour and aceta-zolamide the first line drug if medication is still really required. INTERACTIONS: The gastrointestinal side effects can be exacerbated if mixed with NSAI drugs in-
cluding Aspirin or ibuprofen.
ETHICS: For recreational mountaineering the use of corticosteroids has to be a personal decision but
the risk/benefit equation is very different from acetazolamide since the potential side effects, interac-
tions and problems are much greater.
2.11 Erythropoietin (E.P.O.), blood doping and haemodilution
Drugs such as recombinant EPO, continuous erythropoiesis activator factor, novel erythropoietin
stimulating protein (NESP) aim to increase the formation of oxygen carrying red blood cells (erythro-
poesis) at altitude and have been used by competitive athletes to increase low altitude performance.
There is no doubt that blood doping by autotransfusion of stored blood taken from an athlete and then transfused prior to competition does increase sea level performance (36). Just as EPO is used to try to increase the oxygen carrying capacity of the blood by increasing the number of red blood cells and therefore thickening the blood this comes with the risk of blood clots causing strokes or pulmonary emboli. No research has been done at altitude but logically they might further increase the natural thickening of blood at altitude therefore increasing the risk of clots causing stroke or pulmonary emboli (clots on the lung). Both are potentially fatal conditions. Diluting the blood is designed to make it thinner so making it easier to flow through the blood vessels and possibly carrying more oxygen faster. It has not been shown to work at high altitude and may result in less oxygen being carried (37). The fact that EPO, autotransfusion and haemodilution "treatments", which have contradictory effects, have all been tried illustrates that this is based on dubious theory rather than medical evidence. In reality increased thickness (viscosity) of the blood results in reduced cardiac output and increase vis-cosity results in less oxygen carrying capacity in the blood. All have associated risks. It is possibly best to rely on sophisticated natural changes in the blood which occur with acclimatisation and have evolved over millions of years. 2.12 Ginkgo Biloba
This plant falls into the antioxidant radical scavenger class but in many countries is sold as a herbal
medication without the strict formulation regulations of the established national and international
pharmaceutical bodies. It is therefore difficult to assess its true efficiency and is subject to conflicting
evidence (38, 39, 40, 41 & 42).
2.13 Ibuprofen
In 2012 two papers were published looking at the possible use of ibuprofen in the prevention of AMS
based on the hypothesis that its antiprostaglandin anti-inflammatory properties may be relevant(43 &
44). The jury is still very much out after these two papers and Ken Zafren gives a good summary of
the evidence and pitfalls in an editorial in the Wilderness and Environmental Medicine (45).
It is also known that ibuprofen is used to mask soft tissue pain in endurance mountain marathon run-ners and in sport climbers. PROS: weak evidence in the above papers.
CONS: Real risk of gastrointestinal bleeds associated with this group of drugs which may be in-
creased at altitude with the associated physiological stress of acclimatisation. In a dehydrated individ-
ual the known risk of renal failure is greatly increased.
UIAA MedCom Standard No.22a: Drugs in Mountaineering (lay version)
2.14 Inhaled Steroids
Word has got round the mountaineering community that inhaled steroids such as beclomethasone
reduce the symptoms of high altitude cough. This is unproven. Due to the uncritical acceptance by lay
mountaineers of this perceived benefit a recent attempt to study this possible effect of inhaled steroids
at Everest Base Camp struggled to enrol sufficient subjects who were willing to use a placebo as one
critical arm of the study (46).
CONS: Not expected to ameliorate AMS. Unresearched. Can predispose to oral infections.
2.15 Low molecular weight Heparins
There is no evidence that these anticoagulants prevent AMS, HAPE or HACE. Some people have
advocated their use to minimise the real risk of cerebrovascular events (strokes) at altitude. They re-
quire self injection and being heat labile require special arrangements for transport and storage (47).
Like Aspirin they increase risks of bleeding and are potentially dangerous.
2.16 Nifedipine
Nifedipine is the drug of choice to buy time for the vital descent in the management of HAPE. Used
like this it can be a life saver. It does not treat or prevent AMS. It has been shown to aid in the preven-
tion of HAPE in susceptible individuals who, more importantly, must adopt a gradual ascent profile
(48).
CONS: As with any powerful potentially lifesaving drugs nifedipine has side effects. If used for preven-
tion it cannot be used for treatment. If the patient is taking any other drug from the same calcium
channel blocker class it should be avoided due to a combined effect on lowering blood pressure. The
long list of recognised side effects in some people include dizziness, flushing, peripheral oedema (po-
tentially dangerous in tight boots predisposing to frostbite), insomnia, drowsiness and depression (49).
INTERACTIONS: Marked hypotension if used in very dehydrated people or if combined with a phos-
phodiesterase type-5 inhibitor (eg sildenafil "Viagra" or tadalafil "Cialis"). At altitude only slow release
nifedipine preparations should be used.
2.17 Dietary Nitrate (Beetroot Juice)
Excessive inorganic nitrate within our diet has long been associated with several harmful side effects,
yet hard evidence is far from conclusive. In contrast, recent scientific literature increasingly acknowl-
edges the beneficial role of nitrate supplementation (e.g. concentrated beetroot juice) with respect to
health and exercise. The exact underlying mechanisms remain unclear, however a strong hypothetical
justification is presented for the effective use of beetroot juice to improve performance at altitude,
where the conversion of dietary nitrate to its biologically active derivative, nitric oxide, may be en-
hanced. (50, 51, 52, 53, 54).
PROS: Well constructed double blind, placebo controlled studies have shown very promising results
thus far, including increased exercise tolerance and reduced oxygen consumption during exercise and
rest.
CONS: I) Individuals are cautioned against inorganic and organic nitrate confusion. II) Despite exciting
initial findings, altitude and dose specific evidence still requires greater clarity. III) Side effects of
chronic supplementation have yet to be examined, with specific sub-populations expected to present
sensitivity and potential hypotensive concerns with overconsumption. IV) No apparent protection from
AMS symptoms
2.18 Opiates
These narcotic drugs include codeine, dihydrocodeine, tramadol, fentanyl, morphine and are used in
some sports to mask pain. This may have some advantage in extreme rock climbing but, ignoring
obvious ethical implications, brings risks, especially at altitude.
UIAA MedCom Standard No.22a: Drugs in Mountaineering (lay version) To some degree all can depress breathing, cause drowsiness, reduce reaction times and risk appre-ciation, induce constipation and are potentially addictive. 2.19 Oxygen
ETHICS: The ethics of oxygen use have been extensively debated since the 1920s and will continue
to be debated for many years to come. There is no doubt that oxygen is a drug, available only on pre-
scription in many countries and that it increases performance at altitude. Some would say that any
drug or artificial aid which increases performance is not acceptable for climbing and every mountain-
eer will express great respect for the very few climbers who have summited Mount Everest or other
8000m peaks without using artificial oxygen. On Mount Everest this is just over 60 out of a total of over
5000 ascents!
With this background it is not surprising that the oxygen section of this paper caused more debate within the UIAA Medcom members than any other section. In this area there is direct conflict between our ethics as doctors to help people maintain optimum heath whereas our ethics as mountaineers accept a degree of personal risk and tend to want to minimise the use of artificial aids. For altitudes below 5000m given time most people can acclimatise naturally so they can climb peaks of over 6000m from a high camp without using artificial oxygen. It is only well above 7000m where the pros and cons debate is truly relevant. PROS: Artificial oxygen provides the human body with the one drug it really needs at extreme altitude!
There are no interactions. Anybody doubting its effectiveness should read Edmund Hillary's account of
the use of the first reliable system for the summit push on the first ascent of Everest (55). Despite the
oxygen and supply system weighing 30 pounds its benefit was obvious when the mask was removed.
Climbers now use lightweight cylinders and a much more sophisticated and reliable delivery system.
One study looked at the death rate in mountaineers attempting Everest without oxygen(56) another study looked at the death rates on both Everest and K2 (57). Both showed that the death rates in those not using oxygen were much higher. Do these alone justify the use of oxygen? Two studies show that the brains of mountaineers operating at extreme altitude demonstrate changes on MRI scans but do not look at functional changes (58 & 59). One paper looked for evidence of neu-rological impairment in acclimatised individuals climbing to 7500m and showed no deterioration (60). CONS: Cost, weight, bulk, cylinder supplies, reliability (now much improved), potentially major prob-
lems if supply runs out or delivery system suddenly fails. Due to their weight many climbers seem
reluctant to carry used cylinders down the mountain resulting in unsightly littering. In the event of an
extreme altitude rescue being attempted both the casualty and the rescuers will require extensive
oxygen supplies.
PHYSIOLOGY: Oxygen does not affect performance at sea level, because neither the amount of
available oxygen nor its partial pressure is the limiting factor for maximal performance. This changes
dramatically with decreasing inspiratory oxygen partial pressure (piO2) at extreme altitude, where the
oxygen flow from the atmosphere to the mitochondria is limited by decreased piO2 or capillary-
mitochondrial ∆pO2, respectively. As a consequence, the ascent rate as an indicator of performance
decreases significantly.
CONCLUSION: Again it is for the individual climber to make their own choice. There is little doubt that
the use of oxygen at extreme altitude reduces the risks of death. It does not improve performance at
low altitude.
2.20 Progesterone
On the theory that some women acclimatised better at different stages of their menstrual cycle a 1999
study looked at men at altitude in Peru taking the female hormone Progesterone in the interests of
science. This hormone is known to be a mild respiratory stimulant. This was a small study but no sta-
tistical difference was seen between those taking the active drug and those taking placebo (61).
PROS: The paper's author does not remember any long term side effects (62)
CONS: The drug does not work!
UIAA MedCom Standard No.22a: Drugs in Mountaineering (lay version) 2.21 Phosphodiesterase type-5 inhibitors eg sildenafil (Viagra), ta-
dalafil (Cialis).
This is another group of drugs that lay mountaineers have latched onto for potential mountaineering performance enhancement at altitude. These drug's effects on inhibiting the effect on hypoxic pulmo-nary resistance at altitude is well documented (63). There is little published evidence on the therapeu-tic effect at altitude but one study does suggest that they may reduce the incidence of HAPE (64). These drugs have been adopted by doctors as an additional treatment for HAPE but based mainly on studies of individual cases and small scale studies rather than hard evidence (65). CONS: Currently limited evidence. Potential for side effects such as headache.
2.22 Psychotropic Drugs
Some climbers believe that these substances may be of advantage on some "risky" climbs because of
their euphoric properties. Mescaline and tetrahydrocannabiol (THC) has been used for several ex-
treme big-wall climbs. Their use in Yosemite is documented by Steve Roper (66). Route names like
"Mescalito" clearly indicate the circumstances of the first ascent.
CONS: All these drugs increase reaction time and reduce the risk management capability. Therefore
they may be extremely dangerous if used when mountaineering. There are no data available about the
degree of use in the climbing community.
2.23 Rhodiola crenulata
Extract of this plant is widely used in Tibet and the Himalaya to prevent AMS. It is a proven ACE in-
hibitor and alpha-amylase inhibitor. A double blind placebo controlled crossover study of 102 adults
showed no evidence that it had any effect on AMS (67).
2.24 Salmeterol
The inhaled long acting beta2 agonist, salmeterol, was investigated for the prevention of HAPE (68).
On the strength of this the WMS guidelines now suggest that it may help in the management of HAPE
in combination with other therapy such as DESCENT and nifedipine. It is used in high doses which are
close to the toxic level (125 micrograms twice a day).
With this poor evidence some lay mountaineers have assumed that it may also increase performance. There is no evidence for this and at high doses at altitude they may suffer important side effects such as tremor, tachycardia and dangerous heart rhythms, nausea, dizziness. A case study on one climber using a drug combination of salmeterol with sildenafil and acetazolamide for secondary prevention of HAPE during his second attempt to summit on Everest is based entirely on theoretical research and despite being unreliable may have influenced the behaviour of other climbers who have taken it out of context (69). 2.25 Sleep Medication
Poor sleep is a commonly reported feature of travel to high altitude. The main concern when consider-
ing the use of sleep medications at high altitude is whether the sleep disruption is an environmental
effect (discomfort or unfamiliarity with the setting) or a physiological one related to poor acclimatization
or an over-active respiratory response to high altitude leading to intermittent or "periodic breathing"
(70). With this in mind it is important to realise that most traditional sleep medications if used at alti-
tude will worsen AMS if it is present. There is no evidence to support that sleep medications such as
benzodiazepines worsen hypoxia in otherwise well acclimatized individuals even above 5000m (71).
Equally there are no studies which document the exact effect of sedative sleep medications on people
UIAA MedCom Standard No.22a: Drugs in Mountaineering (lay version) with known AMS. Acetazolamide has been clearly shown to have a beneficial effect on sleep distur-bances at altitude especially those related to poor acclimatization. However it comes at a slight cost as depending on individual susceptibility the diuretic effect of acetazolamide (meaning the individual needs to urinate more in the night) may disturb sleep just as much as the sleep disorder it is treating. Subjective reports suggest the quality of the sleep produced and the general feeling of well being is improved approximately equally with benzodiazepines and acetazolamide although no studies have effectively compared one to the other in a robust ( double blind cross over ) study with a large cohort. If sleep disturbance is present and is due to acute mountain sickness or poor acclimatization, the first line of action should be to prevent or treat that underlying cause (eg by slow ascent or descent) and sleep medications are NOT recommended. However, if there are no other factors present and the individual is extremely well acclimatized, with no other signs or symptoms of AMS it is not unreason-able to consider sleep medications. This would be equivalent to considering the same intervention at sea level, it is neither recommended, appropriate nor acceptable to all individuals (at sea level or alti-tude) and each case should be considered on its individual merit. There is a great deal of literature on the dangers of sleep deprivation on judgment and safe decision making and in some of these circum-stances judicious use of sleep medication might be considered as a safe pathway to enable descent. Using them to ensure safe ascent is an ethical decision. Advantages: Acetazolamide, clearly defined physiological role in improving AMS and sleep at alti-
tude. It is therefore a safer first line assuming the sleep disturbance is physiological and not environ-
mental
Advantages: Low dose of benzodiazepines (such as 10mg Temazepam) treats both physiological (periodic breathing) and environmental causes and that sleep quality and sleep structure have been shown to be improved. Many authorities prefer to use benzodiazepines with short half lives such as Zopidem or Zopliclone. Disadvantages: Acetzolamide are all of those included in the section above on its use in AMS, as
well as small increase in need to urinate at night (which might be detrimental to sleep process). In
addition it may not help with environmental causes and so only treats "half the picture".
With benzodiazepines, if AMS is not clearly excluded, there is a theoretical risk of worsening AMS and hypoxia especially if a higher dose of Temazepam is use (greater than 15mg) . However to date there are few if any studies describing the exact effects of high doses of benzodiazepine at altitude, but common sense and experience suggest higher doses are inadvisable at altitude and in any doses where AMS is clearly documented. 2.26 Theophylline
The theophylline group of drugs are known to be respiratory stimulants that work by increasing adeno-
sine concentration in the breathing centre of the brain and have been shown to increase athletic per-
formance at sea level (72) and to slightly reduce AMS symptoms at altitude (73 & 74). It has also been
seen to improve sleep at altitude (75 & 76). Interestingly caffeine is a chemical relative of this group of
drugs.
CONS: They have narrow therapeutic index meaning that anything that effects the blood level such as
dehydration, alcohol, smoking, drug interactions or even viral illness could lead to potentially danger-
ous toxicity. A low dose of 250mg slow release was studied and showed no such adverse effects.
INTERACTIONS: This group of drugs have multiple interactions with other drugs and have a narrow
therapeutic range. This means that with acetazolamide they can decrease the potassium level in the
blood to potentially dangerous levels and if combined with Azithromycin, which is often used to treat
traveller's Diarrhoea, it can easily reach toxic levels.
UIAA MedCom Standard No.22a: Drugs in Mountaineering (lay version) 3 References
1)
2) Nagat Parbat Pilgrimage by Herman Buhl. Chapter "Above 26,000 ft". 3) Dick Renshaw, personal communication 2013. 4) Wagner DR. Medical and Sporting Ethics of High Altitude Mountaineering: The Use of Drugs ans Supplemental Oxygen (editorial). WEM 23(3): 205-2011 (2012) 6) Subedi et al. Complications of Steroid Use on Mount Everest. W&EM 21, 245-348. 2010 7) L Dumont, C Mardirosoff and M Tramer. Efficacy and harm of pharmacological prevention in acute mountain sickness; quantitave systematic review. BMJ Vol 321 p 267-72. 8) Health & Height. Proceedings of the 5th World Congress on Mountain Medicine and High Altitude Physiology 2002. Pub 2003 University of Barcelona. Drug abuse in the Mountains by Dr Franz Berghold pp 99-106. 9) Bartsch P and Swenson ER "Acute High-Altitude Illness" N Engl J Med 13; 368: 2294-302. 2013. 10) Luks AM, McIntosh SE, Grissom CK et al "Wilderness Medical Society consensus guidelines for the prevention and treatment of acute altitude illness" W&EM Vol21, issue 2 P146-155. June 2010. 11) Gaillard S, Dellasanta P, Loutan L, and Kayser B. Awareness, prevalence, medication use, and risk factors of acute mountain sickness in tourists trekking around the Annapurnas in Nepal: A 12-year follow-up High Alt Med Biol 5:410–419 2004 12) Kilner T and Mukerji S. 2010. Acute mountain sickness prophylaxis: Knowledge, attitudes, & be- haviours in the Everest region of Nepal. Travel Med Infect Dis 8:395–400. 13) Küpper T et al. RIMAT1 study, unpublished data to be used for RIMAT2, in preparation. 14) Roggla G, Roggla M et al. Amphetamine doping in leisure-time mountain climbing at a medium altitude in the Alps. Schweiz Z Sportmed Vol 41, Issue 3 p 103-105 1993) 15) Küpper T, Ebel K, Gieseler U. Modern Mountain and Altitude Medicine. Gentner, Stuttgart, 2010 16) J Trauma. 2006 Dec;61(6):1517-25. "Injury patterns and safety practices of rock climbers" Gerdes EM, Hafner JW, Aldag JC 17) West JB, Schoene RB, Luks Am, Milledge JS "High Altitude Medicine and Physiology" CRC Press, 5th Edition 2013. 18) Cain SM, Dunn JE. "Increase of arterial oxygen tension at altitude by carbonic anhydrase inhibi- tion" J Appl Physiol. 1965 Sep;20(5):882-4. 19) Swenson ER, Teppema LJ "Prevention of acute mountain sickness by acetazolamide: as yet an unfinished story" J Appl Physiol 102, 1305-7 2007. 20) Basnyat B, Gertsch JH, Holck PS et al "Acetazolamide 125mg bd is not significantly different from 375mg bd in the prevention of acute mountain sickness: the prophylactic acetazolamide dosage comparison for efficiency (PACE) trial." HAM&B 7, 17-27. 2006. 21) Leaf D E, Goldfab D S, Mechanisms of action of acetazolamide in the prophylaxis and treatment of acute altitude sickness. Journal of Applied Physiology Vol 102. No 4. 1313-1322 April 2007. 22) Greene MK, Kerr AM, McIntosh IB, and Prescott RJ. (1981). Acetazolamide in prevention of acute mountain sickness: A double-blind controlled cross-over study. Br Med J (Clin Res Ed) 283:811–813. 23) R Greene "Some Medical Aspects" chapter in "Everest 1933" by Hugh Ruttledge published Hod- der and Stoughton 1934. 24) Hackett P H. "Caffeine at High Altitude: Java at Base Camp" HAM&B Vol11 No1 2010. UIAA MedCom Standard No.22a: Drugs in Mountaineering (lay version) 25) Boos, C, et al., Medikamentenmißbrauch beim Freizeitsportler im Fitnessbereich. Dt Ärztebl, 1998. 95(16): p. B774-B781. 26) British National Formulary (BNF) 65 2013 4.7.3 27) Jafarian S et al. "Low dose gabapentin in treatment of high-altitude headache" Cephalalgia 2007;27:1274-1277. 28) Jafarian S et al. "Sumatripan for the prevention of acute mountain sickness" Ann Neurol. 2007;62:273-277. 29) Burtschler M et al "Ibuprofen verses sumatripan for high altitude headache" Lancet 346, 254-255. 30) Burtschler M et al. "Aspirin for the prophylaxis against headache at high altitudes: randomised, double blind, placebo controlled trial" BMJ Vol 316, 1057-1058. 31) Donegani, E; Hillebrandt, D; Windsor, J; Gieseler, U; Rodway, G; Schoffl, V; Kupper, T; "Pre exist- ing Cardiovascular conditions and high altitude. Consensus statement of the medical commission UIAA. Travel Med Inf Dis (TMAID) Vol: 12 Issue 3 Pp: 237-252. May- June 2014. 32) Conway R. EvansI, Weeraman D. "Assesing travellers' knowledge and use of Coca for altitude illness" Wilderness Environ Med. 2012 Dec;23(4):373-4. doi: 10.1016/j.wem.2012.06.005. Epub 2012 Oct 4. 33) Johnson TS et al. "Prevention of Acute Mountain Sickness by Dexamethasone" N Eng J Med 310. 34) Ellsworth AJ. "Acetazolamide or dexamethasone use verses placebo for acute mountain sickness prophylaxis" Am J Med 83. 1024-30. 1991. 35) Luks AM et al "Wilderness Medical Society Consensus guidelines for the prevention and treatment of ACUTE Altitude Illness" W&EM Vol 21 Issue 2 P145-155 June 2010. 36) Jelkman W, Lundby C, "Blood doping and its detection". Blood 118, 2395-404. 37) Young AJ et al. "Effects of erythrocyte infusion on VO2 max at high altitude". J Appl Physiol 81, 38) Leadbetter G et al. "Ginkgo biloba does- and does not-prevent acute mountain sickness". W&EMJ 39) Dumont L et al. Efficacy and harm of pharmacological prevention of acute mountain sickness: quantitative systematic review. BMJ 321: 107-114 (2000) 40) Gertsch JH et al. Ginko biloba for the prevention of severe acute mountain sickness (AMS) start- ing one day before rapid ascent. High Alt Med Biol 3(1): 29-37 (2992) 41) Basnyat B. High altitude illness. Lancet 361(9373): 1967-74 (2003). 42) Bartsch P et al. Acute mountain sickness: controversies and advances High Alt Med Biol 5(2): 43) Lipman GS et al "PAINS group. Ibuprofen prevents altitude illness: a randomised controlled trial for prevention of altitude illness with non-steroidal anti-inflammatories Ann Emerg Med. 2012;59:484-490 44) Gertsch JH et al "Altitude sickness in climbers and efficiency of NSAIDs in trail (ASCENT): Ran- domised, controlled trial of ibuprofen verses placebo for prevention of altitude illness" W&EM 23.307-315 (2012). 45) Zafren K. W&EM 23. 297-299 (2012). 46) Basnyat B personal communication. Nepal 28.8.13. 47) Kupper T et al. Drugs and drug administration in extreme climates. J Travel Med 13(1): 35-47 48) Bartsch P et al. "Prevention of high-altitude pulmonary edema by nifedipine" N Engl J Med 1991; 49) British National Formulary BNF No 65. 2013: 2.6.2. UIAA MedCom Standard No.22a: Drugs in Mountaineering (lay version) 50) Weitzberg et al. "Dietary nitrate- a slow train coming" J Physiol 2011; 589.22. 5333-5334. 51) Vanhatalo et al. Dietary nitrate reduces muscle metabolic perturbation and improves exercise tol- erance in hypoxia. J Physiol 589.22 (2011) pp 5517–5528. 53) Masschelein et al. Dietary nitrate improves muscle but not cerebral oxygenation during exercise in hypoxia. J Appl Physiol 113:736-745, 2012. 54) Muggeridge et al. A single dose of beetroot dose enhances cycling performance in simulated alti- tude. Medicine and Science in Sports and Exercise in print June 2013. 55) Ascent of Everest by John Hunt 1953 and multiple reprints. 56) Pollard A & Clarke C deaths during mountaineering at extreme altitude. Lancet Vol 331, Issue 8597. p 1277. 1988. 57) Huey R B and Eguskitza X. Supplemental Oxygen and Mountaineer Death Rates on Everest and K2 JAMA Vol 284 No2 181, 2000. 58) Garrido E, Castelló A, Ventura JL, Capdevila A, Rodríguez FA. Cortical atrophy and other brain magnetic resonance imaging (MRI) changes after extremely high-altitude climbs without oxygen. Int J Sports Med. 1993;14(4):232-4 59) Fayed N, Modrego PJ, Morales H "Evidence of brain damage after high-altitude climbing by means of magnetic resonance imaging. Am J Med. 2006;119(2):168.e1-6. 60) Tobias M M et al "Cognitive performance high-altitude climbers: a comparative study of saccadic eye movements and neuropsychological tests". European Journal of Applied Physiology DOI 10.1007/s00421-013-2635-6. 61) Hillenbrand P, et al "A randomised controlled trail of progesterone in preventing altitude sickness. Proceedings of the 11th Hypoxia symposium. Jasper 1999. 62) Hillenbrand P. Personal communication 28.8.13. 63) West JB, Schoene RB, Luks AM, Milledge JS "High Altitude Medicine and Physiology" 5th Edition. CRC Press 2013. section 12.6 cardiovascular Responses with multiple references. 64) Maggorini M. et al "Both Tadalafil and dexamethasone may reduce the incidence of high-altitude pulmonary edema: a randomised trial". 65) Meta-Analysis of Clinical Efficacy of Sildenafil, a Phosphodiesterase Type-5 Inhibitor on High Alti- tude Hypoxia and Its Complications by Yu Xu, Yuliang Liu et al. HAM&B Vol:15 No:1 2014 P46-51. 66) Roper S. "Camp 4, recollections of a Yosemite Rockclimber" Chapter 10 "Bringing down the cur- 67) Te-Fa Chiu et al. "Rhodiola crenulata extract for prevention of acute mountain sickness: Compli- mentary and A 2013, 13.298. 68) Sartori c et al. "Salmeterol for the prevention of high-altitude pulmonary edema" NEJM 346;1631- 69) Dunin-Bell O and Boyle S. "Secondary Prevention of HAPE in a Mount Everest Summiter" High Altitude Medicine & Biology. Fall 2009, 10(3): 293-296. 70) Kupper T et al. Cheyne stokes breathing at high altitude: a helpful response or a troublemaker? Sleep Breath 12(2): 123-127 (2008) 71) Dubowitz G. Effect of temazepam on oxygen saturation and sleep quality at high altitude: random- ized placebo controlled crossover trial. BMJ 316(7131): 587-589 (1998) 72) Pigozzi F et al "Oral theophylline supplementation and high-intensity intermittent exercise". J Sports Med Phys Fitness, 43(4): p 535-8. 2003. 73) Fischer R et al. "Theophylline improves acute mountain sickness". Eur Respir J. 15; 123-7. 2000. 74) Kupper T et al. "Prevention of acute mountain sickness with Theophylline" Proceedings of the 11th Hypoxia symposium. Jasper. 1999. 75) Kupper T et al. "Low dose theophylline improves ventilation at night and prevents symptoms of acute altitude sickness at high altitude" J trav Med 15(5);307-314 2008. UIAA MedCom Standard No.22a: Drugs in Mountaineering (lay version) 76) Fischer r et al. "Theophylline and acetazolamide reduce sleep disordered breathing at high alti- tude" Eur Resp J 23(1); 47-52 2004). 4 Members of UIAA MedCom (in alphabetical order)
A. Akca (Turkey), G. Agazzi (Italy), C. Angelini (Italy), B. Basnyat (Nepal), J. Bogg (Sweden), A.R. Chiocconi (Argentina), E. v. Delft (South Africa), N. Dikic (Serbia), W. Domej (Austria), P. Dobbelaar (Netherlands), E. Donegani (Italy), Y. El-Sheikh (Canada), S. Ferrandis (Spain), U. Gieseler (Ger-many), A. Gurtoo (India), U. Hefti (Switzerland), D. Hillebrandt (U.K.), J. Holmgren (Sweden), V. Is-mayil (Azerbaijan), A. Koukoutsi (Greece), A. Kokrin (Russia), B. Komoni (Kosovo), P. Konczakowski (Poland), J. Kubalova (Czech Republic), T. Kuepper (Germany), E. Mashkovsky (Russia), K. Matsuba-yashi (Japan), J. McCall (Canada), H. Meijer (Netherlands), M. Michailov (Bulgaria), J. Milledge (U.K.), D. Moens (Belgium), A. Morrison (U.K.), H. Mosaedian (Iran), R. Naeije (Belgium), M. Nakashima (Japan), S. Omori (Japan), P. Peters (Luxembourg), G. Rodway (USA), G.G. Roi (Italy), I. Rotman (Czech Republic), V. Schoeffl (Germany), J. Shahbazi (Iran), J.C. Skaiaa (Norway), H. Stave (Nor-way), J. Venables (New Zealand), S.-H. Wang (Taiwan), J. Windsor (U.K.) Guest authors:
G. Dubowitz, (San Francisco, California, USA) and J Arnold (UK.) 5 History of this recommendation paper
This advice paper was first conceived by the UIAA Medical Commission in 2008 but differing national,
cultural, medical and mountaineering attitudes resulted in repeated delays in reaching a consensus.
The concept of a factual and non judgmental paper was accepted by all members at the annual Med-
com meeting in Sweden in 2011. Work continued at the meeting in Canada in 2012 and Poland in
2013 with E mail discussions between. At the 2014 meeting in Bolzano in Italy it was decided to pro-
duce this paper for lay readers and a more detailed and technical paper for medical professionals
which is planned to initially be published in peer reviewed medical journal. This version was approved
at Bolzano in May 2014 with minor amendments.

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In collaboration with the American College of Veterinary Surgeons Treating Navicular Syndrome in Equine Patients*R. Wayne Waguespack, DVM, MS, DACVSR. Reid Hanson, DVM, DACVS, DACVECC Auburn University Abstract: Navicular syndrome is a chronic, progressive condition affecting the navicular bone and bursa, deep digital flexor tendon (DDFT), and associated soft tissue structures composing the navicular apparatus. The treatment options for navicular syndrome are

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Minor Research Project A study on Lok Adalat with special reference to the Satara City University Grant Commission, New Delhi Dr. Deepa Pravin Patil Ismailsaheb Mulla Law College, Satara CERTIFICATE This is to certify that a copy of the final report of Minor Research Project entitled "A Study on Lok Adalat in Satara City" by Dr. Deepa