Recent developments in the toxicology of anabolic steroids

Nandrolone decanoate relieves joint pain in hypogonadal men: a novel prospective pilot study and review of the literature

Testosterone is an archetypal androgenic-anabolic steroid (AAS), while its exogenous administration is considered to be the gold standard for the treatment of male hypogonadism. The benefits are not due to its intrinsic nature alone but are due to the result of its interactions with the androgen receptor (AR). As the management of hypogonadism continues to advance into the modern era, it would be preferable for modern andrologists to have multiple tools at their disposal to influence AR activity. Nandrolone, or 19-nortestosterone, is one such compound. In the following review of the literature, we examine the history, pharmacology, and clinical applications of this medication. We also present the results of our novel pilot study examining the favorable effects of nandrolone on joint pain for hypogonadal men.

Biochemical and physiological aspects of endogenous androgens

This review attempts to give a synopsis of the major aspects concerning the biochemistry of endogenous androgens, supplemented with several facets of physiology, particularly with respect to testosterone. Testosterone continues to be the most common adverse finding declared by World Anti-Doping Agency accredited laboratories, such samples having an augmented testosterone to epitestosterone ratio. Knowledge regarding the precursors and metabolism of endogenous testosterone is therefore fundamental to understanding many of the issues concerning doping with testosterone and its prohormones, including the detection of their administration. Further, adverse findings for nandrolone are frequent, but this steroid and 19-norandrostenedione are also produced endogenously, an appealing hypothesis being that they are minor by-products of the aromatization of androgens. At sports tribunals pertaining to adverse analytical findings of natural androgen administration, experts often raise issues that concern some aspect of steroid biochemistry and physiology. Salient topics included within this review are the origins and interconversion of endogenous androgens, the biosynthesis of testosterone and epitestosterone, the mechanism of aromatization, the molecular biology of the androgen receptor, the hypothalamic-pituitary-testicular axis, disturbances to this axis by anabolic steroid administration, the transport (binding) of androgens in blood, and briefly the metabolism and excretion of androgens.

Side effects of anabolic androgenic steroids: pathological findings and structure-activity relationships

Side effects of anabolic steroids with relevance in forensic medicine are mainly due to life-threatening health risks with potential fatal outcome and cases of uncertain limitations of criminal liability after steroid administration. Both problems are typically associated with long-term abuse and excessive overdose of anabolic steroids. Side effects may be due to direct genomic or nongenomic activities (myotrophic, hepatotoxic), can result from down-regulation of endogenous biosynthesis (antiandrogenic) or be indirect consequence of steroid biotransformation (estrogenic).Logically, there are no systematic clinical studies available and the number of causally determined fatalities is fairly limited. The following compilation reviews typical abundant observations in cases where nonnatural deaths (mostly liver failure and sudden cardiac death) were concurrent with steroid abuse. Moreover, frequent associations between structural characteristics and typical side effects are summarized.

Pharmacology of anabolic steroids

Athletes and bodybuilders have recognized for several decades that the use of anabolic steroids can promote muscle growth and strength but it is only relatively recently that these agents are being revisited for clinical purposes. Anabolic steroids are being considered for the treatment of cachexia associated with chronic disease states, and to address loss of muscle mass in the elderly, but nevertheless their efficacy still needs to be demonstrated in terms of improved physical function and quality of life. In sport, these agents are performance enhancers, this being particularly apparent in women, although there is a high risk of virilization despite the favourable myotrophic-androgenic dissociation that many xenobiotic steroids confer. Modulation of androgen receptor expression appears to be key to partial dissociation, with consideration of both intracellular steroid metabolism and the topology of the bound androgen receptor interacting with co-activators. An anticatabolic effect, by interfering with glucocorticoid receptor expression, remains an attractive hypothesis. Behavioural changes by non-genomic and genomic pathways probably help motivate training. Anabolic steroids continue to be the most common adverse finding in sport and, although apparently rare, designer steroids have been synthesized in an attempt to circumvent the dope test. Doping with anabolic steroids can result in damage to health, as recorded meticulously in the former German Democratic Republic. Even so, it is important not to exaggerate the medical risks associated with their administration for sporting or bodybuilding purposes but to emphasize to users that an attitude of personal invulnerability to their adverse effects is certainly misguided.

Steroid and prescription medicine abuse in the health and fitness community: A regional study

BACKGROUND

The purpose of this study was to identify the prevalence of abuse of certain prescription medicines (POM) amongst health club attendees. The non-therapeutic use of such medicines has previously been considered to be restricted to the professional athlete.

METHODS

In the summer of 2005, health club users in the South Wales area were given questionnaires and asked to return them in a stamped, addressed envelope. Anonymity of the respondents was assured.

RESULTS

From the distribution of 210 questionnaires, the response rate was 69.5% (146 questionnaires). The mean age of the sample was 33.6+/-6.7 years (range 15-72 years). Anabolic-androgenic steroid (AAS) use is prominent amongst recreational gym users in this regional sample, with 70% (102 individuals) reporting AAS use, 65.8% (96 individuals) of whom were currently still using. Some 7% of respondents (10 individuals) were female and they also reported taking medication. This research demonstrated an enormous increase in the use of growth hormone (24%), insulin (14%), and tamoxifen (22%), with smaller increases in other drugs.

CONCLUSION

Drug users were from all levels of society and reported various physiological and psychological side effects from their use. The present study indicated that the most used medicine/drug from less than reputable sources was still AAS but that, as a consequence of the internet revolution, they were being caught up by the more expensive designer drugs, particularly growth hormone. Physicians and medical personnel must become aware that the use of AAS and other prescription medicines is on the increase and appears to be predominantly used for cosmetic reasons.

Current perspectives on anabolic steroids

Steroids are used outside the realm of competitive athletics in Australia among a wide variety of groups with different motivations and goals. This paper provides an overview of the reasons for use; rates of usage; physical and psychological side effects; and sources of steroids. Issues associated with injecting steroids; their current legal status; and drug education and prevention programmes are reviewed briefly. Research involving identified sub-populations is needed to determine user profiles and prevalence rates of users and potential users. Studies of Australian users are also needed to obtain baseline information on areas of potential harm associated with steroids use, e.g. aggressive behaviour, needle-sharing behaviour, physical side effects and potential for dependency. It is concluded that future deterrence strategies should focus more on demand reduction, rather than supply.

Chronic Administration of Nandrolone Decanoate Does Not Increase the Plasma Homocysteine Level of Male Rats

Androgenic-anabolic steroids are used widely by many athletes in order to increase muscle mass and strength. Since plasma total homocysteine, an independent risk factor of vascular diseases, is higher in men than in women, it has been proposed that androgenic hormones could increase the plasma total homocysteine level and it might play some role in sudden death when used at supraphysiological doses. To study the association between the use of androgenic-anabolic steroids and plasma homocysteine level, nandrolone decanoate was administered in 3 and 10 mg/kg doses to male rats by intramuscular weekly injections. Control animals received the solvent of nandrolone decanoate. After 14 weeks, plasma total homocysteine level was measured. In order to make sure about the adequacy of doses and bioavailability of drug, testes parameters were also considered. While all testes parameters were suppressed significantly, no association between androgenic-anabolic steroids use and total homocysteine level was found. It is concluded that chronic administration of nandrolone decanoate does not have any significant effect on plasma total homocysteine of male rats. Thus, factors other than plasma total homocysteine level may contribute to increased cardiovascular events after chronic abuse of androgenic-anabolic steroids.

Anabolic steroid abuse: physiological and anaesthetic considerations

This review summarises the physiological and pharmacological effects of the anabolic steroids used to enhance performance in sports. The anabolic steroids promote muscle growth and protein synthesis. Side-effects of anabolic steroids include cardiomyopathy, atherosclerosis, hypercoagulopathy, hepatic dysfunction, and psychiatric and behavioural disturbances. It is therefore appropriate that the anaesthetist be familiar with the abuse of anabolic steroids, their potential adverse effects, and the peri-operative risk associated with the use of these drugs.

Use of ion trap gas chromatography–multiple mass spectrometry for the detection and confirmation of 3′hydroxystanozolol at trace levels in urine for doping control

Stanozolol, a synthetic anabolic androgenic steroid, is often abused in sports to enhance performance. Consequently, the anti-doping laboratories daily screen for its metabolites (3'hydroxystanozolol and 4beta hydroxystanozolol) in all urines, mainly by GC-MS, after enzymatic hydrolysis and TMS derivatization. A sensitive and specific method by GC-MS(3) has been developed for the identification in urine of 3'hydroxystanozolol at trace levels. Full mass spectra and diagnostic ions are presented and a case report is commented. In this case, it was possible to attest the presence of a low concentration of stanozolol metabolite in a sample obtained from a competition test. This would have not been possible with other analytical techniques used in the laboratory. Through this case report, it was also possible to demonstrate the importance of sampling and the difficulties that has to face the laboratory when the pre-analytical step is not correctly performed.

The anabolic androgenic steroid oxandrolone in the treatment of wasting and catabolic disorders: review of efficacy and safety

There has been increasing interest in the development of effective agents that can be safely used to promote anabolism in the clinical setting for patients with chronic wasting conditions as well as in the prevention and treatment of frailty associated with loss of muscle tissue in aging (sarcopenia). One such agent is the anabolic androgenic steroid (AAS) oxandrolone, which has been used in such clinical situations as HIV-related muscle wasting, severe burn injury, trauma following major surgery, neuromuscular disorders and alcoholic hepatitis for over 30 years. In the US, oxandrolone is the only AAS that is US FDA-approved for restitution of weight loss after severe trauma, major surgery or infections, malnutrition due to alcoholic cirrhosis, and Duchenne's or Becker's muscular dystrophy. Our review of the use of oxandrolone in the treatment of catabolic disorders, HIV and AIDS-related wasting, neuromuscular and other disorders provides strong evidence of its clinical efficacy. Improvements in body composition, muscle strength and function, status of underlying disease or recovery from acute catabolic injury and nutritional status are significant in the vast majority of well designed trials. However, oxandrolone has not yet been studied in sarcopenia.Unlike other orally administered C17alpha-alkylated AASs, the novel chemical configuration of oxandrolone confers a resistance to liver metabolism as well as marked anabolic activity. In addition, oxandrolone appears not to exhibit the serious hepatotoxic effects (jaundice, cholestatic hepatitis, peliosis hepatis, hyperplasias and neoplasms) attributed to the C17alpha-alkylated AASs. Oxandrolone is reported to be generally well tolerated and the most commonly documented adverse effects are transient elevations in transaminase levels and reductions in high density lipoprotein cholesterol level.However, optimal risk:benefit ratios for oxandrolone and other agents in its class will need to be refined before widespread clinical acceptance of AASs as a therapeutic option in sarcopenia and other chronic wasting conditions.

Hepatatis in growth promoter treated cows

Adult female beef cattle found positive for stanozolol in the urine were investigated for liver pathology. In all the animals toxic hepatitis was found, including cholestasis, periportal fibrosis and inflammation, focal necrosis and blood filled lacunae. As no clinical data of the cows were available, apart from the history of illegal stanozolol abuse, it is not possible to attribute all changes to the illegal hormone treatment. Moreover, the cows have probably been treated with a cocktail, and apart from stanozolol more anabolic steroids may have been used. Management factors, viral and bacterial infections, former caesarean sections and especially feeding regime may also be responsible for the lesions described. Striking similarities with data from hepatotoxicity found in human body builders using similar agents, however, suggest a major role of stanozolol as causative agent.

Testing of the anabolic stanozolol in human hair by gas chromatography-negative ion chemical ionization mass spectrometry

A sensitive, specific and reproducible method for the quantitative determination of stanozolol in human hair has been developed. The sample preparation involved a decontamination step of the hair with methylene chloride and the sonication in methanol of 100 mg of powdered hair for 2 h. After elimination of the solvent, the hair sample was solubilized in 1 ml 1 M NaOH, 15 min at 95 degrees C, in the presence of 10 ng stanozolol-d3 used as internal standard. The homogenate was neutralized and extracted using consecutively a solid-phase (Isolute C18) and a liquid-liquid (pentane) extraction. After evaporation of the final organic phase, the dry extract was derivatized using 40 microl MBHFA-TMSI (1000:20, v/v), incubated for 5 min at 80 degrees C, followed by 10 microl of MBHFBA, incubated for 30 min at 80 degrees C. The derivatized extract was analyzed by a Hewlett-Packard GC-MS system with a 5989 B Engine operating in the negative chemical ionization mode of detection. Linearity of the detector response was observed for stanozolol concentrations ranging from 5 to 200 pg/mg with a correlation coefficient of 0.998. The assay was capable of detecting 2 pg of stanozolol per mg of hair when approximately 100 mg hair material was processed, with a quantification limit set at 5 pg/mg. Intra-day precision was 5.9% at 50 pg/mg and 7.8% at 25 pg/mg with extraction recoveries of 79.8 and 75.1%, respectively. The analysis of a 3-cm long hair strand, obtained from a young bodybuilder (27 year old) assuming to be a regular user of Winstrol (stanozolol, 2 mg), revealed the presence of stanozolol at the concentration of 15 pg/mg.

Anabolic-androgenic steroid administration causes hypertrophy of immobilized and nonimmobilized skeletal muscle in a sedentary rabbit model

Although the use of anabolic agents in athletics has generated extensive publicity and controversy, the potential therapeutic benefits of these drugs have not been fully investigated. This randomized, blinded experimental study investigated whether short-term administration of an anabolic-androgenic steroid can limit immobilization-induced muscle atrophy in a rabbit model. We casted one hindlimb each in 48 New Zealand White rabbits and randomly assigned the rabbits to two groups. The treated group received weekly intramuscular injections of the anabolic-androgenic steroid, nandrolone decanoate (15 mg/kg). Immobilization significantly decreased muscle weights in both the treated rabbits and controls. Compared with controls, the body weights of the treated rabbits increased significantly at 2, 4, and 8 weeks. At 4 and 8 weeks, wet weights, dry weights, and contractile forces were significantly greater in both the casted and noncasted tibialis anterior muscle-tendon units of the treated group. Dry weights and casted contractile forces of the extensor digitorum longus muscle unit at 4 weeks and all measures at 8 weeks were greater in the treated rabbits than in controls. These results are contrary to previously accepted views that anabolic-androgenic steroid use leads to muscle hypertrophy only in conjunction with strength training. This study adds to the growing evidence that anabolic-androgenic steroids can produce significant skeletal muscle hypertrophy in sedentary populations.

Testing for anabolic steroids in hair from two bodybuilders

Two male bodybuilders were recently arrested by the French customs in Strasbourg (France) in possession of 2050 tablets and 251 ampoules of various anabolic steroids. It was claimed that the steroids were for personal use and not for trafficing as suggested by the police. Urine and hair specimens were collected from both suspects to clarify the claims. Nandrolone, stanozolol, testosterone and their corresponding metabolites were identified in the urine of both subjects. After decontamination, the hair was hydrolyzed by sodium hydroxide in presence of deuterated internal standards. After extraction with ethyl acetate and silylation, the drugs were identified by GC-MS in the electron impact mode. Hair from both males were positive for nandrolone (196 and 260 pg/mg), testosterone (46 and 71 pg/mg) and stanozolol (135 and 156 pg/mg), clearly indicating steroids abuse. Although not yet recognized by the International Olympic Committee, hair analysis may be a useful adjunct to conventional drug testing in urine from athletes.

Drug doping in senior Australian rules football: a survey for frequency

OBJECTIVES

To determine by survey whether the frequency of use of performance enhancing drugs (drug doping) is significant in elite players of Australian Rules football, and to compare this frequency with that in other competitions.

METHODS

Randomised unannounced prospective urine testing during the period 1990-95 of players from the Australian Football League out of competition, in competition matches, and in finals matches; testing was performed according to Olympic International Committee protocols and standards. The players' identities and clubs were unknown during testing.

RESULTS

Of 900 random urine tests, no positive results were obtained for anabolic steroids, diuretics, caffeine, or peptide hormones. Five positive results (0.6%) were obtained-for pseudoephedrine in two instances, and for probenecid, methoxyphenamine, and dextropropoxyphene in one instance each. Each were inadvertent medical doping and declared before testing.

CONCLUSIONS

Drug doping is not a problem in the Australian Football League. This is probably because no doping method is considered to be of value to Australian Rules football, because an educational programme is run by football authorities, and because random during season and out of season testing for drugs occurs.

Anabolic steroid abuse and cardiac death

OBJECTIVE

To examine the relationship between anabolic steroid abuse and cardiac death. We report the first two cases in Australia. They are the only reported cases in which the anabolic steroid oxymesterone has been detected. This compound has never been approved for use in Australia.

CLINICAL FEATURES

Two footballers, aged 18 and 24, sustained fatal cardiac arrests while at training sessions. Both were considered fit and healthy.

OUTCOME

Autopsy revealed features of a hypertrophic cardiomyopathy in the 18-year-old; the 24-year-old had findings of a myocarditis. In both cases the coronary arteries were normal and there was no evidence of coronary thrombosis. Urine in both subjects contained the anabolic steroid oxymesterone.

CONCLUSIONS

There are limited clinical uses for anabolic steroids but they are widely abused by athletes in attempts to alter lean body mass and strength. Acute non-fatal myocardial infarction was first reported in 1988 and fatal myocardial infarction in 1990. While a causal relationship is hard to prove, it is possible that the anabolic steroid contributed to the increase in cardiac size in the first subject and may have increased his responsiveness to catecholamines causing an arrhythmogenic event. In the second, the inflammatory changes could have provided the focus for an arrhythmia. It would appear that anabolic steroid abuse should be considered in any athlete presenting with an acute vascular event.

Endocrine causes of hypertension in children

Hypertension in children is not a common problem. When it is found, however, a pathologic cause can often be identified. The endocrine causes of hypertension in children are generally rare. We have reviewed the diverse and rare endocrine causes of hypertension in the pediatric population. Table 3 lists features of these conditions that assist in their diagnosis. In all patients with hypertension, a thorough history and physical examination may point to the diagnosis of endocrine or other causes of secondary hypertension. For a more detailed approach to these diagnoses, other reviews may be helpful. A phased laboratory evaluation similar to that suggested by Ogborn and Crocker facilitates in the evaluation of secondary hypertension. The critical screening tests from an endocrine point of view are plasma sodium, potassium, calcium, renin activity, and thyroid function tests, including T4, T3, and thyroid stimulating hormone. Measurement of a 24-hour urine collection for aldosterone, metanephrine, and catecholamines may be warranted if the previously mentioned studies are unrevealing. More specific studies also may be suggested by these preliminary evaluations and the history and physical examination. Further investigations should be done with the additional guidance of a pediatric endocrinologist.