A Primer on Anabolic A Primer on Anabolic Steroid Use in HIV Steroid Use in HIV
InfectionInfectionAntonio E. Urbina, M.D.Antonio E. Urbina, M.D.
Medical Director of HIV/AIDS Education and Medical Director of HIV/AIDS Education and TrainingTraining
St. Vincent Catholic Medical Center-ManhattanSt. Vincent Catholic Medical Center-Manhattan
A Local Performance Site of the New York/New A Local Performance Site of the New York/New Jersey AETCJersey AETC
Anabolic SteroidsAnabolic Steroids DefinitionsDefinitions Commonly Used AgentsCommonly Used Agents Indications/DiagnosisIndications/Diagnosis
HypogonadismHypogonadism HIV WastingHIV Wasting
Adverse EffectsAdverse Effects StudiesStudies ManagementManagement
DefinitionsDefinitions Androgens: all male sex hormones, usually Androgens: all male sex hormones, usually
testosterone, but also testosterone testosterone, but also testosterone derivativesderivatives
Androgenic: refers to masculinizing Androgenic: refers to masculinizing properties such as libido, aggression, acne, properties such as libido, aggression, acne, hair growth and losshair growth and loss
Anabolic: refers to assimilation of nitrogen Anabolic: refers to assimilation of nitrogen into tissue (muscle growth)into tissue (muscle growth)
Cannot completely separate one from the Cannot completely separate one from the otherother
Testosterone & Testosterone & DerivativesDerivatives
O
OH
19-Nor
A-RingModifications
5-Reduction
17-Esterification& 17-Alkylation
Target Organs and Physiological Target Organs and Physiological EffectsEffects
of Testosterone and Metabolitesof Testosterone and Metabolites Skin (Skin ( facial/ body facial/ body
hair, sebum hair, sebum production)production)
Bone (Bone ( BMD) BMD) Muscle (Muscle ( lean mass, lean mass,
strength)strength) Adipose Tissue (Adipose Tissue ( lipo- lipo-
lysis, lysis, abdominal fat) abdominal fat) Blood (Blood ( hematocrit) hematocrit) Immune system (Immune system (
auto-antibody auto-antibody production)production)
CNS (CNS ( libido, well-being, libido, well-being, aggression, spatial aggression, spatial cognition)cognition)
Hypothalamus/ Pituitary Hypothalamus/ Pituitary (( GnRH, LH, FSH; GnRH, LH, FSH; GH) GH)
Larynx (lowers voice)Larynx (lowers voice) Breast (EBreast (E22 size) size) Liver (Liver ( SHBG, HDL) SHBG, HDL) Kidney (Kidney ( erythropoietin) erythropoietin) Genitals (Genitals ( development, development,
spermatogenesis, spermatogenesis, erections)erections)
Prostate (Prostate ( size, secretions) size, secretions)
Androgenic vs AnabolicAndrogenic vs Anabolic AndrogenicAndrogenic
Testosterone (IM)Testosterone (IM) Androgel Androgel
(transdermal)(transdermal) Androderm Androderm
(transdermal)(transdermal)
AnabolicAnabolic Deca-Durabolin Deca-Durabolin
(IM)(IM) Oxandrin (oral)Oxandrin (oral) Anadrol (oral)Anadrol (oral)
Mean Steady-State Testosterone Concentrations in Patients Receiving AndroGel®
Day 90
Data on file. Unimed Pharmaceuticals, Inc.
Production and RegulationProduction and Regulationof Testosteroneof Testosterone
T = testosteroneT = testosteroneOnly 2% is free testosteroneOnly 2% is free testosteroneand 98% is boundand 98% is bound
Free TFree T2%2%
SHBG-bound TSHBG-bound T60%60%
Albumin-Albumin-bound Tbound T
38%38%
Adapted from Bagatell CJ, Bremner WJ. Adapted from Bagatell CJ, Bremner WJ. N Engl J MedN Engl J Med. . 1996;334:707-715.1996;334:707-715.
GnRHGnRH
LHLH FSHFSHTestosteroneTestosterone
TestosteroneTestosterone
SpermSperm
HypothalamusHypothalamus
PituitaryPituitary
TestisTestis
Adapted from Braunstein GD. In: Adapted from Braunstein GD. In: Basic & Clinical EndocrinologyBasic & Clinical Endocrinology. . 5th ed. Stamford, Conn: Appleton & Lange; 1997:403-433.5th ed. Stamford, Conn: Appleton & Lange; 1997:403-433.
Laboratory Diagnosis and Laboratory Diagnosis and Workup of Primary vs. Workup of Primary vs.
Secondary HypogonadismSecondary Hypogonadism Hypogonadism in adult male - presence of Hypogonadism in adult male - presence of
signs or symptoms of hypogonadism with signs or symptoms of hypogonadism with confirmation by laboratory testingconfirmation by laboratory testing
Laboratory TestingLaboratory Testing:: AM total testosterone x 2 AM total testosterone x 2
Normally diurnal rhythm with highest levels in AMNormally diurnal rhythm with highest levels in AM Free testosterone (2%) - (sometimes even if Free testosterone (2%) - (sometimes even if
total normal)total normal) Bioavailable testosterone - free (2%) plus Bioavailable testosterone - free (2%) plus
loosely bound to albumin (38%) - (total 40%)loosely bound to albumin (38%) - (total 40%) 60% tightly bound to SHBG60% tightly bound to SHBG
Diagnosis and Workup of Diagnosis and Workup of Primary vs. Secondary Primary vs. Secondary Hypogonadism (Cont.)Hypogonadism (Cont.)
LH and FSH - (if low T is established or as initial LH and FSH - (if low T is established or as initial workup); Repeat with 2 samples taken 20-30 min. workup); Repeat with 2 samples taken 20-30 min. apart and pooled apart and pooled FSH and LH secreted in short pulsesFSH and LH secreted in short pulses
Prolactin ; Estradiol (if gynecomastia or testicular or Prolactin ; Estradiol (if gynecomastia or testicular or adrenal tumor suspected)adrenal tumor suspected)
Definitive diagnosis of T deficiency on the basis of Definitive diagnosis of T deficiency on the basis of laboratory tests for the aging male has not been laboratory tests for the aging male has not been establishedestablished <200 ng/dL clearcut<200 ng/dL clearcut total T may not be an accurate measurement if there is total T may not be an accurate measurement if there is
increased or decreased SHBGincreased or decreased SHBG deficiency considered at 200-350 ng/dL (depending on assay) deficiency considered at 200-350 ng/dL (depending on assay)
or if the T or bioavailable T (or free T) is in the lower range of or if the T or bioavailable T (or free T) is in the lower range of normalnormal
Diagnosis and Workup of Diagnosis and Workup of Primary vs. Secondary Primary vs. Secondary Hypogonadism (Cont.)Hypogonadism (Cont.)
If studies indicate clear primary hypogonadismIf studies indicate clear primary hypogonadism Low T with reciprocal elevated FSH and LHLow T with reciprocal elevated FSH and LH Then pituitary workup not indicatedThen pituitary workup not indicated
If studies indicate secondary hypogonadism or If studies indicate secondary hypogonadism or combined:combined: Low T with low FSL/LH orLow T with low FSL/LH or Low T with normal or high-normal FSH/LH - not Low T with normal or high-normal FSH/LH - not
appropriately elevatedappropriately elevated Then MRI of pituitary indicatedThen MRI of pituitary indicated
MRI of pituitary always indicated if elevated prolactinMRI of pituitary always indicated if elevated prolactin Other pituitary testing may be necessaryOther pituitary testing may be necessary
Stimulation tests generally of limited clinical value to Stimulation tests generally of limited clinical value to distinguish 1º from 2º or pituitary from hypothalamic distinguish 1º from 2º or pituitary from hypothalamic defectdefect
AACE Guidelines, Endocrine Practice:8,439,2002
Medications (common) Medications (common) contribute to hypogonadismcontribute to hypogonadism
Glucocoticoids - testicular and Glucocoticoids - testicular and pituitary/hypothalamicpituitary/hypothalamic
ketoconazole - inhibitor of gonadal and adrenal ketoconazole - inhibitor of gonadal and adrenal steroidogenesissteroidogenesis
spironolactone - aldosterone antagonist; and spironolactone - aldosterone antagonist; and blocks androgen at receptor,inhibits androgen blocks androgen at receptor,inhibits androgen biosynthesis, interferes with binding T to SHBGbiosynthesis, interferes with binding T to SHBG
cimetidine - weak antiandrogencimetidine - weak antiandrogen finasteride (propecia) - inhibitor of typeII finasteride (propecia) - inhibitor of typeII
5alpha reductase, antiandrogen5alpha reductase, antiandrogen flutamide and other antiandrogensflutamide and other antiandrogens megastrol acatate (megace) - decreased megastrol acatate (megace) - decreased
androgen production and androgen mediated androgen production and androgen mediated actionaction
Testosterone Deficiency Testosterone Deficiency with Agingwith Aging
Decline in Testosterone with ageDecline in Testosterone with age Decrease in testosterone productionDecrease in testosterone production Decrease in testosterone clearanceDecrease in testosterone clearance Increase in SHBGIncrease in SHBG
may be due to higher serum estradiol levels from may be due to higher serum estradiol levels from increased adipose tissueincreased adipose tissue
Therefore, bioavailable T decreases more than Therefore, bioavailable T decreases more than total Ttotal T
Circadian rhythm (higher T values in AM) lost Circadian rhythm (higher T values in AM) lost with agingwith aging
Tenover,L.J. End.Metab.Clinics NA:27,969,1998
Dobs AS. Baillière’s Clin Endocrinol Metab. 1998;12:379-390.Grinspoon S, et al. J Clin Endocrinol Metab. 2000;85:60-65.
Wiley S, et al. AIDS. 2003; 17(2): 183-8. Habasque C, et al. Mol Hum Reprod 2002 8(5): 419-25.
Prevalence and Prevalence and Diagnosis ofDiagnosis of
Hypogonadism In HIVHypogonadism In HIV Approximately 30% of HIV+ men and 50% Approximately 30% of HIV+ men and 50% of men with AIDS are hypogonadalof men with AIDS are hypogonadal Correlated with stage of disease, lymphocyte Correlated with stage of disease, lymphocyte
depletion, weight loss, reduced muscle mass, depletion, weight loss, reduced muscle mass, and decreased functional statusand decreased functional status
Free testosterone is the preferred Free testosterone is the preferred measurementmeasurement
Sex hormone binding globulin (SHBG) Sex hormone binding globulin (SHBG) increases in men with HIV-infectionincreases in men with HIV-infection
Grinspoon S, et al. Ann Intern Med. 1998;129:18-26.
Effects of Testosterone in Effects of Testosterone in Hypogonadal Men With AIDS Hypogonadal Men With AIDS
WastingWastingStudy designStudy design 6-month, randomized, placebo-controlled trial 6-month, randomized, placebo-controlled trial 51 men with hypogonadism and AIDS wasting51 men with hypogonadism and AIDS wasting Randomly assigned to receive testosterone Randomly assigned to receive testosterone
enanthate 300 mg or placebo IM every 3 enanthate 300 mg or placebo IM every 3 weeks weeks
Testosterone
Fat-Free Mass (n=21)
Lean Body Mass (n=22)
Muscle Mass (n=21)
-1.5-1
-0.50
0.51
1.52
2.53
3.5
Cha
nges
, kg
No Testosterone
Fat-Free Mass (n=19)
Lean Body Mass (n=19)
Muscle Mass (n=18)
-1.5-1
-0.50
0.51
1.52
2.53
3.5
Cha
nges
, kg
Grinspoon S, et al. Ann Intern Med. 1998;129:18-26.
Effects of Testosterone in Effects of Testosterone in Hypogonadal Men With AIDS Hypogonadal Men With AIDS
WastingWasting
Bhasin S, et al. JAMA. 2000;283:763-770.
IM Testosterone Therapy and IM Testosterone Therapy and Resistance Exercise in Resistance Exercise in
Hypogonadal HIV+ MenHypogonadal HIV+ MenStudy designStudy design A 16-week, placebo-controlled, double-blind, A 16-week, placebo-controlled, double-blind,
randomized trialrandomized trial 61 HIV+ men, aged 18 to 50 years old61 HIV+ men, aged 18 to 50 years old Randomized to 1 of 4 groupsRandomized to 1 of 4 groups
Placebo, no exercise (n=14)Placebo, no exercise (n=14) Testosterone enanthate 100 mg/wk, Testosterone enanthate 100 mg/wk,
no exercise (n=17)no exercise (n=17) Placebo and exercise (n=15)Placebo and exercise (n=15) Testosterone and exercise (n=15)Testosterone and exercise (n=15)
Bhasin S, et al. JAMA. 2000;283:763-770.
IM Testosterone Therapy and IM Testosterone Therapy and Resistance Exercise in Resistance Exercise in
Hypogonadal HIV+ MenHypogonadal HIV+ Men
Study resultsStudy results weight in testosterone alone or weight in testosterone alone or
exercise aloneexercise alone maximum voluntary muscle strength maximum voluntary muscle strength
in all 4 treatment groupsin all 4 treatment groups Greater Greater in thigh muscle volume in thigh muscle volume
in T alone or PRE alonein T alone or PRE alone lean body mass with testosterone or T + PRElean body mass with testosterone or T + PRE hemoglobin in testosterone recipientshemoglobin in testosterone recipients
Grinspoon S, et al. Ann Intern Med. 2000;133:348-355.
IM Testosterone and/or IM Testosterone and/or Exercise in Exercise in
Eugonadal Men With AIDS Eugonadal Men With AIDS WastingWastingStudy design Study design
12-week randomized, controlled trial12-week randomized, controlled trial 54 eugonadal men with AIDS wasting 54 eugonadal men with AIDS wasting Randomized to testosterone enanthate Randomized to testosterone enanthate
200 mg/wk or placebo and progressive resistance 200 mg/wk or placebo and progressive resistance training (3x/wk) or no exercisetraining (3x/wk) or no exercise
0
200
400
600
800
1000
1200
1400
Arm Leg Arm Leg
Intervention Placebo
Cha
nge
in M
uscl
e M
ass,
mm
2
Progressive Exercise(3 times/wk)
IM Testosterone (200 mg/wk)
P=.004
P=.045
P=.001 P=.002
Grinspoon S, et al. Ann Intern Med. 2000;133:348-355.
IM Testosterone and/or Exercise IM Testosterone and/or Exercise in Eugonadal Men With AIDS in Eugonadal Men With AIDS
WastingWasting
BackgroundBackground Despite HAART, HIV-wasting is still very Despite HAART, HIV-wasting is still very
common, affecting up to 30% of patients common, affecting up to 30% of patients in the US and Europe (Wanke et al. 2000, in the US and Europe (Wanke et al. 2000, Balslef et al. 1997)Balslef et al. 1997)
Death due to wasting in patients with Death due to wasting in patients with AIDS is related to the magnitude of tissue AIDS is related to the magnitude of tissue depletion, independent of the underlying depletion, independent of the underlying cause (Kotler DP et al. cause (Kotler DP et al. Am J Clin NutrAm J Clin Nutr. . 1989)1989)
AIDS-Wasting Syndrome AIDS-Wasting Syndrome (AWS)(AWS)
10% involuntary weight loss in last 12 10% involuntary weight loss in last 12 monthsmonths
7.5% involuntary weight loss in last 6 7.5% involuntary weight loss in last 6 monthsmonths
5% loss of BCM in last 6 months5% loss of BCM in last 6 months Men: BCM <35% B.W. and BMI <27 kg/mMen: BCM <35% B.W. and BMI <27 kg/m22
Women: BCM <23% B.W. and BMI <27 Women: BCM <23% B.W. and BMI <27 kg/mkg/m22
Polsky, Kotler and Steinhart.
Major Causes of AWSMajor Causes of AWS Reduced food intakeReduced food intake Malabsorption/diarrheaMalabsorption/diarrhea Infections Infections HIV-enteropathy HIV-enteropathy Altered metabolismAltered metabolism MedicationsMedications
Treatment Strategies of Treatment Strategies of AWSAWS
Appetite stimulants (megestrol acetate, Appetite stimulants (megestrol acetate, dronabinol)dronabinol)
Nutritional supplements (beta-hydroxy-beta-Nutritional supplements (beta-hydroxy-beta-methyl-butyrate, glutamine, arginine, vitamins, methyl-butyrate, glutamine, arginine, vitamins, micronutrients, protein)micronutrients, protein)
Cytokine inhibitors (thalidomide, pentoxifyllin)Cytokine inhibitors (thalidomide, pentoxifyllin) Anabolic proteins (human growth hormone, Anabolic proteins (human growth hormone,
Insulin-like growth factor)Insulin-like growth factor) Anabolic steroidsAnabolic steroids Physical exercisePhysical exercise
Oxymetholone as Therapy to Maintain Oxymetholone as Therapy to Maintain Body Composition in HIV-Positive SubjectsBody Composition in HIV-Positive Subjects
(Urbina,A. 2003)(Urbina,A. 2003)
Open label, single center, Phase III study Open label, single center, Phase III study involving pts who have received at least 4 involving pts who have received at least 4 months of prior anabolic (nandrolone or months of prior anabolic (nandrolone or oxandrolone) for a past or current dx of oxandrolone) for a past or current dx of wastingwasting
Pts were then switched to oxymetholone Pts were then switched to oxymetholone 50 mg QD and followed for 6 months50 mg QD and followed for 6 months
Efficacy and safety evaluations performed Efficacy and safety evaluations performed at 4 week interval from baseline through at 4 week interval from baseline through week 12, then q6 weeks until week 24 week 12, then q6 weeks until week 24
Oxymetholone as Therapy Oxymetholone as Therapy to Maintainto Maintain
(Urbina, A 2003)(Urbina, A 2003) Study ObjectivesStudy Objectives
Maintenance (no change) or Maintenance (no change) or improvement (increase) in BCM as improvement (increase) in BCM as measured by BIAmeasured by BIA
Evaluate the effects on HIV replication as Evaluate the effects on HIV replication as measured by change in CD4 and viral measured by change in CD4 and viral load from baselineload from baseline
Evaluate clinical laboratory (hematology, Evaluate clinical laboratory (hematology, lipids, LFTs, testosterone, PSA) and vital lipids, LFTs, testosterone, PSA) and vital sign measurementssign measurements
Oxymetholone as Therapy Oxymetholone as Therapy to Maintainto Maintain
(Urbina, A 2003)(Urbina, A 2003) 16 HIV+ men were successfully 16 HIV+ men were successfully
switched to oxymetholoneswitched to oxymetholone BCM was maintained over the 24 BCM was maintained over the 24
week period with a mean increase of week period with a mean increase of 2.2 lbs (p=.091)2.2 lbs (p=.091)
Increase in FFM for all weeks with Increase in FFM for all weeks with significant increase at 24 weeks (3.1 significant increase at 24 weeks (3.1 lbs, p=0.027)lbs, p=0.027)
Oxymetholone to MaintainOxymetholone to Maintain(Urbina, A 2003)(Urbina, A 2003)
Lipids decreased over time Lipids decreased over time (especially HDL and LDL)(especially HDL and LDL)
Overall, no clinically significant Overall, no clinically significant effect on LFTseffect on LFTs
CD4 values increased over time CD4 values increased over time (mean of 21 cell increase)(mean of 21 cell increase)
Testosterone levels increased by Testosterone levels increased by week 18 and 24week 18 and 24
Oxymetholone to maintainOxymetholone to maintain(Urbina, A 2003)(Urbina, A 2003)
MeasureMeasure ResultResultBMIBMI Increased 0.8Increased 0.8±0.2 ±0.2
((p=0.006p=0.006))FFM (lbs)FFM (lbs) Increased 3.8Increased 3.8±1.5 ±1.5
((p=0.027p=0.027))Waist Waist circumference (cm)circumference (cm)
Decreased 0.4Decreased 0.4±0.9 ±0.9 (p=0.647)(p=0.647)
Triceps skinfold Triceps skinfold measure (cm)measure (cm)
Decreased 0.1Decreased 0.1±0.1 ±0.1 (p=0.424)(p=0.424)
Mid-arm muscle Mid-arm muscle (cm(cm22))
Increased 4.9Increased 4.9±2.0 ±2.0 ((p=.037p=.037))
No TestosteroneTestosterone
-3
-2
-1
0
1
2
3
4
5
Cha
nge
Lum
bar
Spi
ne R
egio
nal B
MD
, %
Fairfield WP, et al. J Clin Endocrinol Metab. 2001;86:2020-2026.
Effects of Testosterone on Effects of Testosterone on Bone Density in Eugonadal Bone Density in Eugonadal
Men With AIDS WastingMen With AIDS Wasting
Bone Density increased significantly in Bone Density increased significantly in response to testosterone (response to testosterone (PP=.02) =.02)
Anabolic Drugs: a Comparison of Clinical Studies
Drug (No of subjects)
Duration (weeks)
Control Arm Inclusion Criteria
Baseline Body Weight
Mean Gain of Weight
Body Composition
Comments
Oxymetholone (n=30) Hengge 1996 Nandrolone Decanoate (n=17) Gold 1996 Nandrolone Decanoate (n=10) Strawford 1999 Oxandrolone (n=10) Romeyn 2000 Oxandrolone (n=21) Berger 1996
12 16 12 12 16
Yes No open-label study No open-label study No pilot-study Yes
Loss of B.W. >10% last 4 mths. Loss of B.W. 5-15 % Loss of B.W. >5% reduced testosterone levels Loss of B.W. >5% reduction of muscle mass Loss of B.W. >10%
56.5 kg (Oxymetholone) 56 kg (Oxy + Ketotifen) 62 kg No data No data No data
5.7 kg (Oxymetholone) 4.4 kg (Oxy + Ketotifen) 2.3 kg 4.9 1.2 kg 2.7 kg Oxandrolone, 3.9 kg + PRE 1.7 kg
No Yes Yes No No
Significant increase of BMI in both groups Good tolerance No increased strength
Grinspoon S. et al. J Clin Endocrinol Metab. 2000;85:60-65.
Depression Indices in Depression Indices in Hypogonadal HIV-Hypogonadal HIV-
Infected MenInfected MenStudy designStudy design 6-month, randomized, placebo-controlled trial 6-month, randomized, placebo-controlled trial 51 men with hypogonadism and AIDS wasting51 men with hypogonadism and AIDS wasting Randomly assigned to receive testosterone Randomly assigned to receive testosterone
enanthate 300 mg or placebo IM every 3 weeks enanthate 300 mg or placebo IM every 3 weeks 10 age and weight matched men with AIDS 10 age and weight matched men with AIDS
wasting who were not hypogonadal were wasting who were not hypogonadal were recruited as a control group for baseline recruited as a control group for baseline comparison only and did not receive testosteronecomparison only and did not receive testosterone
Grinspoon S. et al. J Clin Endocrinol Metab. 2000;85:60-65.
Depression Indices in Depression Indices in Hypogonadal HIV-Hypogonadal HIV-
Infected MenInfected Men Beck Depression InventoryBeck Depression Inventory
Administered to all patients (hypogondal and Administered to all patients (hypogondal and eugonadal) at baseline and again after 6 eugonadal) at baseline and again after 6 months to the hypogonadal patients in the months to the hypogonadal patients in the randomized studyrandomized study
Normal range <10Normal range <10
N=5115.5 +1
N=1010.6 +1.4
*P=.02
Depression Indices in Depression Indices in Hypogonadal HIV-Hypogonadal HIV-
Infected MenInfected Men
Grinspoon S. et al. J Clin Endocrinol Metab. 2000;85:60-65.
P< 0.001 n.s.
Depression Indices in Depression Indices in Hypogonadal HIV-Hypogonadal HIV-
Infected MenInfected Men
Grinspoon S. et al. J Clin Endocrinol Metab. 2000;85:60-65.
ADVERSE EFFECTSADVERSE EFFECTS AcneAcne Hair lossHair loss Increased libido (supraphysiologic)Increased libido (supraphysiologic) InsomniaInsomnia Testicular atrophyTesticular atrophy Agressiveness (supraphysiologic)Agressiveness (supraphysiologic) HypertensionHypertension
ADVERSE EFFECTSADVERSE EFFECTS GynecomastiaGynecomastia VirilizationVirilization PolycythemiaPolycythemia Increase in transaminasesIncrease in transaminases
Hepatis peliosisHepatis peliosis Inceased risk with co-infectedInceased risk with co-infected
Hyperlipidemia (↓HDL)Hyperlipidemia (↓HDL) Prostatic enlargementProstatic enlargement
Algorithim for Use of Algorithim for Use of AnabolicsAnabolics
Select appropriate patientSelect appropriate patient Wasting, post-inpatient, after tx of OIWasting, post-inpatient, after tx of OI Hypogonadol vs eugonadolHypogonadol vs eugonadol
Free or bioavilableFree or bioavilable Prior to initiationPrior to initiation
Check LFTs, CBC, PSA and DRECheck LFTs, CBC, PSA and DRE
Algorithim for Use of Anabolic Algorithim for Use of Anabolic SteroidsSteroids
Treatment for short durationTreatment for short duration 3-6 months3-6 months
Monitoring of lab valuesMonitoring of lab values TestosteroneTestosterone LFT’sLFT’s CBCCBC Lipid panelLipid panel PSAPSA
Monitoring PSA during Monitoring PSA during Androgen TherapyAndrogen Therapy
Elevated serum PSA levels Elevated serum PSA levels before or during therapy must before or during therapy must be investigated.be investigated.
Measure PSA at baseline, 6 Measure PSA at baseline, 6 months, then annuallymonths, then annually
Interval increase of PSA of > Interval increase of PSA of > 0.75 ng/ml (even if still in 0.75 ng/ml (even if still in “normal” range) requires “normal” range) requires investigationinvestigation