Can androgen therapy replete lean body mass and improve muscle function in wasting associated with human immunodeficiency virus infection?

Anabolic steroid use: patterns of use and detection of doping

Anabolic-androgenic steroids (AAS) were the first identified doping agents that have ergogenic effects and are being used to increase muscle mass and strength in adult males. Consequently, athletes are still using them to increase physical performance and bodybuilders are using them to improve size and cosmetic appearance. The prevalence of AAS use has risen dramatically over the last two decades and filtered into all aspects of society. Support for AAS users has increased, but not by the medical profession, who will not accept that AAS use dependency is a psychiatric condition. The adverse effects and potential dangers of AAS use have been well documented. AAS are used in sport by individuals who have acquired knowledge of the half-lives of specific drugs and the dosages and cycles required to avoid detection. Conversely, they are used by bodybuilders in extreme dosages with the intention of gaining muscle mass and size, with little or no regard for the consequences. Polypharmacy by self-prescription is prevalent in this sector. Most recently, AAS use has filtered through to 'recreational street drug' users and is the largest growth of drugs in this subdivision. They are taken to counteract the anorexic and cachectic effects of the illegal psychotropic street drugs. Screening procedures for AAS in World Anti-Doping Agency accredited laboratories are comprehensive and sensitive and are based mainly on gas chromatography-mass spectrometry, although liquid chromatography-mass spectrometry is becoming increasingly more valuable. The use of carbon isotope mass spectrometry is also of increasing importance in the detection of natural androgen administration, particularly to detect testosterone administration. There is a degree of contentiousness in the scenario of AAS drug use, both within and outside sport. AAS and associated doping agents are not illegal per se. Possession is not an offence, despite contravening sporting regulations and moral codes. Until AAS are classified in the same capacity as street drugs in the UK, where possession becomes a criminal offence, they will continue to attract those who want to win at any cost. The knowledge acquired by such work can only assist in the education of individuals who use such doping agents, with a view to minimizing health risks and hopefully once again create a level playing field in sport.

Anabolic agents for improving muscle regeneration and function after injury

1. In the present review, we describe how muscles can be injured by external factors, internal factors or during the performance of some actions during sports. In addition, we describe the injury to a muscle that occurs when its blood supply is interrupted, an occurrence common in clinical settings. An overview of muscle regeneration is presented, as well as a discussion of some of the potential complications that can compromise successful muscle repair and lead to impaired function and permanent disability. 2. Improving muscle regeneration is important for hastening muscle repair and restoring muscle function and the present review describes ways in which this can be achieved. We describe recent advances in tissue engineering that offer considerable promise for treating muscle damage, but highlight the fact that these techniques require rigorous evaluation before they can become mainstream clinical treatments. 3. Growth-promoting agents are purported to increase the size of existing and newly regenerating muscle fibres and, therefore, could be used to improve muscle function if administered at appropriate times during the repair process. The present review provides an update on the efficacy of some growth-promoting agents, including anabolic steroids, insulin-like growth factor-I (IGF-I) and beta(2)-adrenoceptor agonists, to improve muscle function after injury. Although these approaches have clinical merit, a better understanding of the androgenic, IGF-I and b-adrenoceptor signalling pathways in skeletal muscle is important if we are to devise safe and effective therapies to enhance muscle regeneration and function after injury.

Transcriptional profiling of testosterone-regulated genes in the skeletal muscle of human immunodeficiency virus-infected men experiencing weight loss

CONTEXT

HIV-associated wasting and weight loss remain clinically significant concerns even in the era of potent antiretroviral therapy. Although androgen treatment increases muscle mass, the cell-intrinsic mechanisms engaged remain poorly understood.

OBJECTIVE

This study was an unbiased approach to identify expression profiles associated with testosterone treatment using genome-wide microarray analysis of skeletal muscle biopsies.

DESIGN, SETTING, AND PARTICIPANTS

Forty-four HIV-positive men with weight loss were randomized to receive either 300 mg testosterone enanthate or placebo injections im weekly for 16 wk. Muscle biopsies were obtained at baseline and on treatment d 14. A subset of specimens was chosen for microarray analysis, with changes in selected genes confirmed by real-time PCR, Western blot analysis, and in vitro culture of muscle precursor cells.

RESULTS

Significantly greater gains in body mass (+2.05 and -1.07 kg, respectively; P = 0.003) and lean body mass by dual-energy x-ray absorptiometry (2.93 vs. 0.35 kg, respectively; P = 0.003) were observed in subjects treated with testosterone compared with placebo. Microarray analysis revealed up-regulation in genes involved in myogenesis and muscle protein synthesis, immune regulation, metabolic pathways, and chromatin remodeling. Representative genes were confirmed by real-time PCR and protein expression studies. In an independent analysis, gene networks that differentiate healthy young men from older men with sarcopenia had substantial overlap with those activated by testosterone treatment.

CONCLUSIONS

These data provide new insights into the mechanisms of androgen action and have implications for both development of muscle biomarkers and anabolic therapies for wasting and sarcopenia.

Therapeutic approaches for muscle wasting disorders

Muscle wasting and weakness are common in many disease states and conditions including aging, cancer cachexia, sepsis, denervation, disuse, inactivity, burns, HIV-acquired immunodeficiency syndrome (AIDS), chronic kidney or heart failure, unloading/microgravity, and muscular dystrophies. Although the maintenance of muscle mass is generally regarded as a simple balance between protein synthesis and protein degradation, these mechanisms are not strictly independent, but in fact they are coordinated by a number of different and sometimes complementary signaling pathways. Clearer details are now emerging about these different molecular pathways and the extent to which these pathways contribute to the etiology of various muscle wasting disorders. Therapeutic strategies for attenuating muscle wasting and improving muscle function vary in efficacy. Exercise and nutritional interventions have merit for slowing the rate of muscle atrophy in some muscle wasting conditions, but in most cases they cannot halt or reverse the wasting process. Hormonal and/or other drug strategies that can target key steps in the molecular pathways that regulate protein synthesis and protein degradation are needed. This review describes the signaling pathways that maintain muscle mass and provides an overview of some of the major conditions where muscle wasting and weakness are indicated. The review provides details on some therapeutic strategies that could potentially attenuate muscle atrophy, promote muscle growth, and ultimately improve muscle function. The emphasis is on therapies that can increase muscle mass and improve functional outcomes that will ultimately lead to improvement in the quality of life for affected patients.

Anabolic steroids for the treatment of weight loss in HIV-infected individuals

BACKGROUND

Individuals with HIV infection often lose weight during the course of their disease. Furthermore, low serum concentrations of testosterone are common in individuals with HIV infection, particularly those with weight loss. Treatment of weight loss with anabolic steroids in HIV-infected individuals may be beneficial.

OBJECTIVES

Our objectives were to assess the efficacy and safety of anabolic steroids for the treatment of weight loss in adults with HIV infection.

SEARCH STRATEGY

We searched the following databases: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, AIDSLINE, AIDSearch, EMBASE, CINAHL, Current Contents, and the National Library of Medicine Gateway Abstracts for controlled trials up to April 2005. We also searched the bibliographies of the identified studies and review the articles. In addition, pharmaceutical manufacturers of anabolic steroids were contacted.

SELECTION CRITERIA

Randomized controlled trials that compared the use of an anabolic steroid to placebo to treat weight loss in adults with HIV were included. Randomized controlled trials that compared the use of anabolic steroids to placebo for the treatment of weight loss in adults with HIV were selected. Change from baseline in lean body mass or in body weight was reported as on outcome measure.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed the trials for quality of randomization, blinding, withdrawals, and adequacy of allocation concealment. For continuous data, weighted mean differences (WMD) were calculated. For dichotomous outcomes, risk differences, were calculated. Because of uncertainty as to whether consistent true effects exist in such different populations and treatments, the authors decided a priori to use random effects models for all outcomes.

MAIN RESULTS

Thirteen trials met the inclusion criteria. Two hundred ninety-four individuals randomized to anabolic steroid therapy and 238 individuals randomized to placebo were included in the analysis of efficacy for change from baseline in lean body mass. Three hundred forty-three individuals randomized to anabolic steroid and 286 randomized to placebo were included in the analysis of efficacy for change from baseline in body weight. The mean methodologic quality of the included studies was 4.1, of a maximum 5 points. Although significant heterogeneity was present for both outcomes, the average change in lean body mass was 1.3 kg (95% CI: 0.6, 2.0), while the average change in total body weight was 1.1 kg (95% CI: 0.3, 2.0). A total of eight deaths occurred during the treatment period; four in the anabolic steroid treatment groups and four in the placebo-treatment groups (risk difference 0.00, 95% CI -0.03, 0.03). The risk difference for withdrawals or discontinuations of study medication due to adverse events was 0.00 (95% CI: -0.02, 0.03).

AUTHORS' CONCLUSIONS

Although the results of the trials were heterogeneous, on average, the administration of anabolic steroids appeared to result in a small increase in both lean body mass and body weight as compared with placebo. While these results suggest that anabolic steroids may be useful in the treatment of weight loss in HIV infected individuals, due to limitations, treatment recommendations cannot be made. Further information is required regarding the long-term benefit and adverse effects of anabolic steroid use, the specific populations for which anabolic steroid therapy may be most beneficial, and the optimal regime. In addition, the correlation of improvement in lean body mass with more clinically relevant endpoints, such as physical functioning and survival, needs to be determined.

Regulation of body composition by androgens

Human body can be viewed simplistically as being composed of fat-free and fat mass. With more sophisticated techniques, body composition can be broken down into fat mass, skeletal muscle mass, nonmuscle lean mass, visceral mass and bone mineral content. Similarly, it is possible to obtain estimates of total body water and intracellular and extracellular water contents. Regardless of the model of body composition assessment, it is evident that androgens are important determinants of body composition; there is no body compartment that is not directly or indirectly affected by androgens. The effects of androgens on skeletal muscle mass have received the greatest attention in recent literature; however, growing body of evidence suggests that androgens also regulate fat mass, bone mineral content, nonmuscle soft tissues and body water.

Androgen effects on body composition

Androgens are known to have a role in the body fat, muscle size, muscle performance and physical function differences seen between hypogonadal and eugonadal men. The results of investigations into effects of testosterone on body composition, fat metabolism and muscle anabolism are reviewed here. Testosterone dose-response relationships are presented in studies of the effects of physiologic and supraphysiologic doses with and without exercise in young hypogonadal men, older men with low testosterone levels and in chronic illness states.

Reversible azoospermia: anabolic steroids may profoundly affect human immunodeficiency virus-seropositive men undergoing assisted reproduction

BACKGROUND

In vitro fertilization (IVF) with intracytoplasmic sperm injection (ICSI) has recently been offered to human immunodeficiency virus (HIV)-serodiscordant couples where the man is seropositive and the woman seronegative to achieve pregnancy while minimizing the risk of HIV transmission. Anabolic steroids are commonly prescribed medications for adjunctive treatment of HIV disease to prevent muscle wasting.

CASE

An HIV-serodiscordant couple presented for fertility care and evaluation. The man was found to be azoospermic. Further evaluation attributed his azoospermia to his treatment with testosterone and oxandrolone. After these agents were discontinued, his azoospermia resolved within 3 months. Normal sperm were then cryopreserved for future use, and his medications were resumed. Later the couple conceived by IVF-ICSI using the cryopreserved sperm.

CONCLUSION

The popular use of anabolic steroids in HIV-infected men may predispose them to abnormal sperm production.

Altered gonadal steroidogenesis in critical illness: is treatment with anabolic steroids indicated?

The physiology of the reproductive system changes dramatically with the onset of major illness. The serum testosterone concentrations fall to pre-pubertal levels secondary to a decreased secretion of gonadotropins and a decreased Leydig cell response to luteinizing hormone. At the same time, the serum oestrogen concentration rises as the result of an increased rate of peripheral aromatization. The clinical consequences of these marked changes are not yet well understood. One line of evidence argues for the administration of anabolic steroids (derivatives of testosterone) to critically ill patients to improve their catabolic state. Another line of evidence in animal models suggests that testosterone may suppress the immune system and myocardial function in critical illness. No clinical trials of oestrogen administration to critically ill patients have been reported, although two animal studies suggest that oestrogen may have a positive effect on survival. This chapter reviews changes in the physiology of the reproductive system in major illness as well as current evidence regarding the clinical effects of androgens and oestrogens in critical illness and their potential therapeutic roles.

Viruses in the mammalian male genital tract and their effects on the reproductive system

This review describes the various viruses identified in the semen and reproductive tracts of mammals (including humans), their distribution in tissues and fluids, their possible cell targets, and the functional consequences of their infectivity on the reproductive and endocrine systems. The consequences of these viral infections on the reproductive tract and semen can be extremely serious in terms of organ integrity, development of pathological and cancerous processes, and transmission of diseases. Furthermore, of essential importance is the fact that viral infection of the testicular cells may result not only in changes in testicular function, a serious risk for the fertility and general health of the individual (such as a fall in testosteronemia leading to cachexia), but also in the possible transmission of virus-induced mutations to subsequent generations. In addition to providing an exhaustive account of the data available in these domains, this review focuses attention on the fact that the interface between endocrinology and virology has so far been poorly explored, particularly when major health, social and economical problems are posed. Our conclusions highlight the research strategies that need to be developed. Progress in all these domains is essential for the development of new treatment strategies to eradicate viruses and to correct the virus-induced dysfunction of the endocrine system.