Androgenic anabolic steroids, modified androgens or prohormones; that promote muscle growth and used to enhance athletic performance or improve physique. Several anabolic steroids have the approval; as therapy of hypogonadism, cachexia, anaemia and other disorders. However, these products can also cause diverse liver abnormalities; including severe and prolonged cholestatic liver injury, peliosis hepatis, hepatic adenoma; and even hepatocellular carcinoma with prolonged use; albeit in a minority of patients.
These risks, as well as cardiovascular injury; hyperlipidaemia, and infertility, along with the development of dependence; have prompted increasing Food and Drug Administration and Drug Enforcement Administration (DEA) regulation of anabolic steroids in the United States. Despite the increased oversight; numerous examples of contamination of bodybuilding supplements; with illegal anabolic steroids have been reported; demonstrating that these supplements remain an important source of illicit anabolic steroid exposure.
Prolonged cholestasis associated with anabolic steroids
Little is known about the pathophysiological mechanisms of prolonged cholestasis; associated with anabolic steroids or who is at risk for developing liver injury. Previous small studies have identified a few variants; associated with genetic cholestatic disorders; in those that develop cholestastic liver injury; after using bodybuilding supplements. Anabolic steroid modifications allowing for oral administration; and those specifically with a C‐17 alkylated modification; are known to be associated with cholestatic liver injury; but a detailed time course of liver injury; histologic evaluation, genetic characterisation and chemical analysis of supplements; in a large cohort is lacking.
The drug‐induced liver injury network (DILIN) has prospectively enrolled patients; with drug or herbal and dietary supplement‐associated liver injury to characterise their clinical features and to generate a well‐phenotyped biospecimen repository for future mechanistic and genetic association studies. A previous review of the DILIN’s experience with herbal and dietary supplement, which constituted the second most common class of agents causing drug‐induced liver injury (DILI), identified supplements advertised to promote bodybuilding as the largest class within this category.
Potential exposure to anabolic steroids
Firstly, patients consuming bodybuilding supplements often presented with a distinct clinical phenotype of a profound cholestatic liver injury in the absence of significant biliary obstruction. However, the current report now describes the clinical features, laboratory findings, histological features and outcomes among 44 consecutive patients enrolled with bodybuilding supplements induced liver injury in this well‐characterised prospective cohort of patients. In addition, chemical analysis of the ingested products in 14 subjects and potential genetic associations; conducted in 41 cases, respectively, to explore potential exposure to anabolic steroids and mechanisms of liver injury.
However, in a study reported in Alimentary Pharmacology & Therapeutics, 44 men with liver injury, attributed to over-the-counter bodybuilding supplements, experienced a uniform and distinctive pattern of signs and symptoms that were often prolonged, difficult to treat, and accompanied by disability and weight loss. So, all participants in the study, enrolled in the National Institute of Health-supported Drug-Induced Liver Injury Network, had jaundice (a yellowing of the eyes and skin) and most had generalized itching leading to hospitalization in 71 percent of patients, although none died or needed a liver transplant.
So, investigators commonly found that the ingested products often contained illicit anabolic steroids not accurately listed on the label. “Anabolic steroids should only be; used under the strict supervision of a physician,” said lead author Dr. Andrew Stolz, of the University of Southern California, Los Angeles in conclusion. “Patients need to inform their care providers if they are taking any form of nutritional supplement and should be especially leery of bodybuilding supplements, which may contain illicit or USA Drug Enforcement Administration controlled anabolic steroids.”