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Abeles RD, Foxton M, Khan S, Goldin R, Smith B, Thursz MR, Verma S. Androgenic anabolic steroid-induced liver injury: two case reports assessed for causality by the updated Roussel Uclaf Causality Assessment Method (RUCAM) score and a comprehensive review of the literature. BMJ Open Gastroenterol 2020; 7:bmjgast-2020-000549. [PMID: 33214235 PMCID: PMC7678230 DOI: 10.1136/bmjgast-2020-000549] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 10/03/2020] [Indexed: 12/11/2022] Open
Abstract
Background Anabolic androgenic steroids (AAS) usage is widespread and increasing. AAS drug-induced liver injury (DILI) is recognised but its clinical course and management is poorly described. We report 2 cases of AAS DILI with associated renal dysfunction, managed successfully with oral corticosteroids. Methods A comprehensive review identified 50 further cases to characterise the clinical and biochemical course. Causality grading was calculated using the updated Roussel Uclaf Causality Assessment Method (RUCAM) score. Data are presented as median values. Results The most common AAS taken was methyldrostanolone. Patients commonly present with jaundice and pruritus but may exhibit other constitutional symptoms. Patients presented 56 days after starting, and bilirubin peaked 28 days after stopping, AAS. Causality assessment was ‘unlikely’ in 1 (2%), ‘possible’ in 31 (60%) and ‘probable’ in 20 (38%). Peak values were: bilirubin 705 μmol/L, alanine transaminase 125 U/L, aspartate transaminase 71 U/L, alkaline phosphatase 262 U/L, gamma-glutamyl transferase 52 U/L, international normalised ratio 1.1. Liver biopsies showed ‘bland’ canalicular cholestasis. 43% of patients developed kidney injury (peak creatinine 225 μmol/L). Therapies included antipruritics, ursodeoxycholic acid and corticosteroids. No patients died or required liver transplantation. Conclusions Physicians are likely to encounter AAS DILI. Causality assessment using the updated RUCAM should be performed but defining indications and proving efficacy for therapies remains challenging.
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Affiliation(s)
- Robin Daniel Abeles
- Divison of Surgery and Cancer, Department of Digestive Diseases, St Mary's Hospital, Imperial College London, London, UK .,Department of Hepatology, Chelsea and Westminster Healthcare NHS Trust, London, UK
| | - Matthew Foxton
- Department of Hepatology, Chelsea and Westminster Healthcare NHS Trust, London, UK
| | - Shahid Khan
- Divison of Surgery and Cancer, Department of Digestive Diseases, St Mary's Hospital, Imperial College London, London, UK
| | - Robert Goldin
- Centre for Pathology, St Mary's Hospital, Imperial College, London, UK
| | - Belinda Smith
- Divison of Surgery and Cancer, Department of Digestive Diseases, St Mary's Hospital, Imperial College London, London, UK
| | - Mark R Thursz
- Divison of Surgery and Cancer, Department of Digestive Diseases, St Mary's Hospital, Imperial College London, London, UK
| | - Suman Verma
- Department of Hepatology, Chelsea and Westminster Healthcare NHS Trust, London, UK
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Pereira E, Moyses SJ, Ignácio SA, Mendes DK, da Silva DS, Carneiro E, Hardy AMTG, Rosa EAR, Bettega PVC, Johann ACBR. Anabolic steroids among resistance training practitioners. PLoS One 2019; 14:e0223384. [PMID: 31618245 PMCID: PMC6795452 DOI: 10.1371/journal.pone.0223384] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 09/02/2019] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE To compare the use of anabolic steroids (AS), the motivation to use them, their side effects, the source of information and the form in which AS were obtained, the medical follow-up, and the periodic examinations in resistance training practitioners who are either current or former users of AS. METHODS A prevalence survey was performed in the gyms of the city of Curitiba, including 719 current and former AS users who self-administered a questionnaire. The chi-square and z of proportions (p <0.05) statistical tests were conducted. RESULTS Esthetics was the main motivation associated with AS intake, leading to satisfactory results. The information about the form in which to use AS was provided by doctors and AS were either purchased at the pharmacy with a prescription or illegally. Current users reported a higher number of cycles and doses, a longer duration of use, as well as larger economical investments into AS. This shows a higher consumption of such drugs, regardless of the medical follow-up and post-cycle therapy. CONCLUSION Given that a change in the usage pattern was observed when increasing the AS consumption, this should be considered in the elaboration of public policies to inhibit such a trend.
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Affiliation(s)
- Ericson Pereira
- Department of Physical Education, Graduate Program, Life Sciences School, Pontifícia Universidade Católica do Paraná, Curitiba, Paraná, Brazil
| | - Samuel Jorge Moyses
- Department of Dentistry, Graduate Program, Life Sciences School, Pontifícia Universidade Católica do Paraná, Curitiba, Paraná, Brazil
| | - Sérgio Aparecido Ignácio
- Department of Dentistry, Graduate Program, Life Sciences School, Pontifícia Universidade Católica do Paraná, Curitiba, Paraná, Brazil
| | - Daniel Komarchewski Mendes
- Department of Physical Education, Graduate Program, Life Sciences School, Pontifícia Universidade Católica do Paraná, Curitiba, Paraná, Brazil
| | - Diego Sgarbi da Silva
- Department of Dentistry, Graduate Program, Life Sciences School, Pontifícia Universidade Católica do Paraná, Curitiba, Paraná, Brazil
| | - Everdan Carneiro
- Department of Dentistry, Graduate Program, Life Sciences School, Pontifícia Universidade Católica do Paraná, Curitiba, Paraná, Brazil
| | - Ana Maria Trindade Grégio Hardy
- Department of Pharmacology, College of Pharmacy and Pharmaceutical Sciences, The University of Toledo, Toledo, Ohio, United States of America
| | - Edvaldo Antônio Ribeiro Rosa
- Department of Dentistry, Graduate Program, Life Sciences School, Pontifícia Universidade Católica do Paraná, Curitiba, Paraná, Brazil
| | - Patrícia Vida Cassi Bettega
- Department of Physical Education, Graduate Program, Life Sciences School, Pontifícia Universidade Católica do Paraná, Curitiba, Paraná, Brazil
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Eapen J, Ayoola R, Subramanian RM. 'The efficacy of extracorporeal liver support with molecular adsorbent recirculating system in severe drug-induced liver injury'. Oxf Med Case Reports 2018; 2018:omx077. [PMID: 29308212 PMCID: PMC5751031 DOI: 10.1093/omcr/omx077] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2017] [Revised: 09/30/2017] [Accepted: 10/10/2017] [Indexed: 01/06/2023] Open
Abstract
We report a case of a 26-year-old man with no significant medical history, who presented with fatigue, pruritus, jaundice, dark urine and clay colored stool for one month. He had been taking methyl-1-etiochoenolol-epietiocholanolone, an androgenic anabolic steroid (AAS). He was initially found to have a total bilirubin (Tbili) of 6 mg/dL. He discontinued the AAS but the patients’ symptoms worsened and Tbili increased to 36 mg/d. This prompted inpatient management of his drug-induced liver injury (DILI). Molecular adsorbent recirculating system (MARS) is an extracorporeal liver support system that replaces the detoxification function of the liver. The patient was initiated on a 4-day trial of MARS therapy. Over the course of his therapy, he clinically improved and his Tbili decreased to 20.7 mg/dL. At follow-up, his symptoms resolved and Tbili was 3.3 mg/dl. This case demonstrates the efficacy of MARS in treating severe cholestatic DILI refractory to standard medical therapy.
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Affiliation(s)
- Jaishvi Eapen
- Department of Medicine, New York University, Langone Health, New York, NY, USA
| | - Rotimi Ayoola
- Department of Medicine, New York University, Langone Health, New York, NY, USA
| | - Ram M Subramanian
- Department of Medicine, Division of Transplant Hepatology, Emory University, Atlanta, GA, USA
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Al-Azzawi H, Patel R, Sood G, Kapoor S. Plasmapheresis for Refractory Pruritus due to Drug-Induced Cholestasis. Case Rep Gastroenterol 2017; 10:814-818. [PMID: 28203129 PMCID: PMC5260533 DOI: 10.1159/000454674] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Accepted: 11/21/2016] [Indexed: 12/18/2022] Open
Abstract
Pruritus can be a distressing symptom seen in various cholestatic disorders. It is treated with medications like bile acid sequestrants. Drug-induced cholestasis usually resolves with withdrawal of the causative medication. We describe a case of refractory pruritus due to drug-induced cholestasis, not improved with withdrawal of the drug, managed effectively with multiple sessions of plasmapheresis.
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Affiliation(s)
- Hasan Al-Azzawi
- Department of Pulmonary, Critical Care and Sleep, Baylor College of Medicine, Houston, TX, USA
| | - Ruchi Patel
- Department of Abdominal Transplantation, Baylor College of Medicine, Houston, TX, USA
| | - Gagan Sood
- Department of Abdominal Transplantation, Baylor College of Medicine, Houston, TX, USA
| | - Sumit Kapoor
- Department of Pulmonary, Critical Care and Sleep, Baylor College of Medicine, Houston, TX, USA
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Treatment of resistant pruritus from cholestasis with albumin dialysis: combined analysis of patients from three centers. J Hepatol 2010; 53:307-12. [PMID: 20580987 DOI: 10.1016/j.jhep.2010.02.031] [Citation(s) in RCA: 88] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2009] [Revised: 01/18/2010] [Accepted: 02/08/2010] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Albumin dialysis using molecular adsorbent recirculating system (MARS) is a new procedure for treating resistant pruritus from cholestasis, but it is usually published as a case report or a short series. Therefore, we analyzed patients with resistant pruritus treated with MARS from three centers, to assess the changes on pruritus and the indices of cholestasis. METHODS Twenty patients (12 female, mean age: 51+/-3.4 years) with chronic cholestatic liver disease or chronic liver-graft rejection were evaluated. The severity of pruritus was assessed using a visual analogue scale (VAS) before and after treatment, and 30 days thereafter. Liver tests, including total bilirubin, alkaline phosphatase, gamma-glutamyl-transferase, cholesterol, triglycerides, and total bile acid were also determined, as well as the number of sessions and the coupled procedure (dialysis or perfusion). RESULTS Albumin dialysis resulted in a decrease of pruritus (VAS: from 70.2+/-4.8 to 20.1+/-4.2, p<0.001), which partially resumed after 30 days (38.7+/-6.6). VAS decreased by 72% immediately after treatment and by 51% after 1 month. Pruritus decreased in all but one patient. MARS resulted in a significant bile acid decrease of 41% after treatment and by 37% after 1 month. The effect of MARS on pruritus and markers of cholestasis was similar in patients with different diseases and was independent of the coupled procedure. The improvement of pruritus in individuals was positive in 75% of patients. No major adverse effects were observed. CONCLUSIONS Albumin dialysis using MARS is an effective procedure for managing resistant pruritus in most patients with chronic cholestasis and graft rejection.
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Silvagni E, Colì L, Stagni B, Stefoni S, Bolondi L. A case of intractable pruritus in Turner's syndrome successfully treated with molecular adsorbent recirculating system. Intern Emerg Med 2008; 3:65-7. [PMID: 18273566 DOI: 10.1007/s11739-008-0094-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2006] [Accepted: 12/01/2006] [Indexed: 12/24/2022]
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Kafrouni MI, Anders RA, Verma S. Hepatotoxicity associated with dietary supplements containing anabolic steroids. Clin Gastroenterol Hepatol 2007; 5:809-12. [PMID: 17509944 DOI: 10.1016/j.cgh.2007.02.036] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The aim of this article was to re-emphasize the hepatotoxicity associated with the use of anabolic androgenic steroids and to highlight the marketing and sale of anabolic androgenic steroids as dietary supplements. METHODS This was a case series of 2 patients who developed a cholestatic liver panel after consumption of anabolic androgenic steroids. A detailed Pubmed/Medline search was performed to research this topic. RESULTS We present 2 young men who developed significant cholestatic liver injury after consumption of anabolic androgenic steroids. This was associated with considerable morbidity, although both patients recovered without the need for a liver transplant. Both of these anabolic androgenic steroids were being marketed as dietary supplements. CONCLUSIONS Despite being classified as class III controlled substances, anabolic androgenic steroids are still a cause for serious hepatotoxicity in the United States. Some of these anabolic androgenic steroids are being marketed as dietary supplements. Although the Food and Drug Administration is making concerted efforts to regulate this, increased vigilance also is required from the medical profession.
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Affiliation(s)
- Michel I Kafrouni
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins University Hospital, Baltimore, Maryland, USA
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