Potential risk for developing severe COVID-19 disease among anabolic steroid users

A severe case of COVID-19 was observed in an otherwise healthy 28-year-old man who had taken oxandrolone 40 mg/day as an anabolic steroid. The patient had been taking oxandrolone for enhanced bodybuilding 30 days prior to presenting to an outpatient clinic with COVID-19 symptoms. The patient reported that his symptoms have rapidly worsened over the course of 4 days prior to presenting at the clinic. As part of an experimental antiandrogen treatment for hyperandrogenic men suffering from COVID-19, he was administered a single 600 mg dose of the novel antiandrogen proxalutamide. Twenty-four hours after administration of this dose, marked improvement of symptoms and markers of disease severity were observed. To our knowledge, this is the first case that potentially links anabolic steroid use to COVID-19 disease severity.

SAT-LB8 The Testosterone-To-Estradiol Ratio, Rather Than Testosterone or Estradiol Alone, Is a More Precise Marker of Metabolic-Related Outcomes in Males: Insights From a Systematic Review

Background:Estradiol (E2) has been shown to exert beneficial effects on males, particularly for metabolic outcomes. However, these benefits tend to be more evident when accompanied by concurrent increase in testosterone (T) levels, when the increase of E2 is secondary to the increase of T. Oppositely to its benefits in healthy males, when under metabolic and inflammatory diseases, E2 has been reported to be a marker of worse prognosis, once E2 is unproportionally high compared to testosterone in pathological conditions, which results in hypogonadism. The collective analysis of T and E2 shows that the balance between these two hormones determines whether increase in E2 levels is physiological or pathological, demonstrated by balanced T and E2, i.e., intact T:E2 ratio compared to healthy males, and disrupted balance between T and E2, with impaired T:E2 ratio, respectivey. Hence, it seems that the dual relationship between E2 and health markers in males is based on the balance, or ratio, between T and E2. The objective of the present study is to propose a ratio between T and E2(testosterone-to-estradiol ratio, or T:E ratio) as a better predictor of health outcomes than testosterone or estradiol alone, and to differentiate health from pathological states within this single marker, from a review of the literature. Methods:We systematically searched for articles using the following criteria: 1. Any of the combinations of the expressions “testosterone” (AND) ”estradiol” (AND) “male(s)” (OR) ”men” (OR) “masculine”, or “testosterone-to-estradiol” (OR) “testosterone:estradiol” (OR) “estradiol-to-testosterone ratio” (OR) “estradiol:testosterone” (AND) “male(s)” (OR) ”men” (OR) “masculine”, to be present in the title and/or abstract; 2. Fully written in English; 3. Performed in humans; 4. Throughout the literature until Jan 30th 202020; and 5. Original researches.Results:We selected 39 articles, from which 27 were performed in healthy males, and 11 under metabolic or inflammatory conditions. Benefits of E2 in healthy males occurred irrespective of T for bone mass and quality, and anger levels. Benefits that were better identified when E2 and T were evaluated together include better libido, improved cognitive functions, improved well-being and other mood states, increased muscle mass, enhanced loss of fat mass, quality, increased basal metabolic rate, increased fat oxidation, and reduced cardiovascular markers, including reduced maximal intimal-media carotids thickness, when T:E ratio was > 13.7. In pathological states, increased estradiol was associated to increased risk of disease-specific complications, and worse quality of life, particularly when T:E was < 9.5. T:E ratio was also able to accurately identify healthy athletes from those affected by any sport-related metabolic conditions.Conclusion:Testosterone-to-estradiol (T:E) ratio is likely a more precise predictor of metabolic-related health outcomes in both healthy and pathological states, compared to testosterone or estradiol alone.

MON-LB305 The “Normal” Hormonal Levels in Athletes: Should Reference Ranges Be Adapted for the Physically Active Population?

Background:Despite the growing number of physically active subjects, including elite and amateur athletes, little is known regarding metabolic and hormonal chronic adaptations to exercises. While the elucidation of the hormonal and metabolic physiological adaptations to physical activity is of emerging importance, the Endocrine and Metabolic Responses on Overtraining Syndrome (EROS) study have serendipitously unveiled the existence of multiple metabolic and endocrine physiological changes in male athletes, including chronic increase of testosterone with concurrent physiological increase of estradiol, enhanced GH and cortisol responses to stimulations,andincreased catecholamines, basal metabolic rate, fat oxidation, and hydration status. These findings were uncovered due to a novel methodological design in which athletes affected by overtraining syndrome (OTS) were compared to a two control groups, of healthy athletes (ATL) and healthy non-physically active controls (NPAC). Since none of the parameters were directly dependent on exercise or performance, differences between these two groups were unexpected. From the fact that several parameters were shown to be different between ATL and NPAC, we realized that the use of the reference ranges for general population to analyze results in athletes may potentially under- and over-diagnose a wide range of conditions. Our objective is therefore to determine whether athletes should be biochemically evaluated through specific adapted ranges, and propose preliminary adaptations in these ranges. Methods: A systematic review on the literature on endocrine and metabolic adaptations to exercise was performed, as well as a thorough analysis of the seven arms of the Endocrine and Metabolic Responses on Overtraining Syndrome (EROS) study. Results:Multiple reference ranges were shown to be inaccurate for athletes. Among the parameters that should be adapted for athletes, and their respective adaptedranges include: 1. Cortisol response to an insulin stimulation test (ITT) (&gt; 20.5 μg/dL); 2. GH response to an ITT (&gt; 12 μg/L); 3. Prolactin response to an ITT (&gt; 22 ng/mL); 4. Salivary cortisol at 8AM (&gt; 450 ng/dL); 5. Total testosterone (&gt; 450 ng/dL); 6. Estradiol (25-45 pg/mL) - and testosterone-to-estradiol ratio maintained &gt; 13.7; 7. Total nocturnal urinary catecholamines (&gt; 220 μg/12h); 8. Resting lactate (&lt; 1.0 nMol/L); 9. Measured-to-predicted basal metabolic rate (BMR) (&gt; 105%); 10. Fat oxidation (in relation to total BMR) (&gt; 50%); and 11. Hydration status (body water &gt; 62% of total body weight). Conclusion: Analysis of biochemical parameters in athleted should be interpreted with cautious, particularly hormonal and metabolic parameters, once many parameters likely undergo adaptive changes when under physical activity. Preliminary adaptations for the ranges have been proposed.

MON-LB100 Novel Paradoxical Markers of Weight Loss: Is the Worse Actually the Better? a Retrospectiveanalysisof 1,567 Patientswith Obesity With Successful Clinical Weight-Loss Approaches

Background:Obesity is a chronic, multi-factorial, and relapsing disorder that has been reported to be a risk factor to more than 200 diseases, among which the majority is direct- or indirectly triggered by the metabolic abnormalities induced by excessive body fat. Indeed, patients with obesity tend to disclose multiple alterations of metabolic markers, which tend to improve with weight loss. Despite the multiple dysfunctions extensively in this population, only mandatory biochemical exams are usually ordered, likely due to limitations in cost and lack of cost-effectiveness, since the majority of the parameters typically altered in obesity does not drive therapeutic choices or influence in an individual-based evaluation.We developed a protocol for obesity treatment that includes a thorough analysis and follow up of the biochemical parameters of patients with obesity, including more than 50 parameters, for more precise diagnosis and response to treatments. Among these parameters, we identified unexpected changes, including some that would initially be related to increased cardiovascular risk or worse prognosis when in an usual context, but which could peculiarly indicate successfulness of weight loss, since these parameters tend to return to normal levels after a period in the new body weight. Our objective is to identify whether these paradoxical changes in biomarkers are linearly correlated with body weight loss, fat loss, mass loss, or whether they were related to the use of any anti-obesity drug. Methods: In a retrospective cohort of 1,567 patients that underwent a clinical weight loss treatment for obesity in a obesity center (Corpometria Institute, Brasília, DF, Brazil), we performed a linear association analysis between body weight and body fat (air displacement pletismography - Bod Pod, CosMed, USA) and 65 parameters, including hormonal, metabolic, inflammatory, and immunologic parameters. We also adjusted for the use of anti-obesity drugs. Results: Homocysteine and triglycerides were identified to increase linearly according to the amount of weight loss (r = -0.77) and fat loss (r = -0.85), but not due to the use of any drug. Folic acid decrease was directly related to fat loss (r = 0.81). Additional findings include more significant decrease of ApoB, compared to LDLc, decreases of GGT, ALT, CRP, ESR, neutrophils, ferritin, fibrinogen, PTH, free T3, uric acid, a and temporary decrease of ApoA and HDLc, all related with body fat loss. Conclusions: Increase of homocysteine resulted from decreased folic acid metabolism, and increased triglycerides may be indirect markers of lipolysis, as no other plausible mechanism could explain these findings.

SAT-LB4 Novel Hormonal and Metabolic Markers of Recovery From Overtraining Syndrome Unveiled by the Longitudinal ARM of the Eros Study - the Eros-Longitudinal Study

Background: Overtraining Syndrome (OTS) is an unexplained underperformance syndrome triggered by excessive training, insufficient caloric intake, inadequate sleep, and excessive cognitive and social demands. Investigations of markers of the challenging recovery from OTS have not been reported to date. The objective of the present study is to describe novel markers, and biochemical and clinical behaviors during the restoration process of OTS.Design: A 12-week interventional protocol in 12 athletes affected by OTS was conducted, including increased food intake, transitory interruption of the trainings, improvement of sleep quality, and management of stress.Methods: We assessed 50 parameters, including hormonal responses to an insulin tolerance test (ITT), basal hormonal and non-hormonal biochemical markers, body metabolism and composition. Results: In response to an ITT, early cortisol (p = 0.026), early GH (p = 0.004), and late GH (p = 0.037) improved significantly. Basal estradiol (p = 0.0002) and nocturnal urinary catecholamines, (p = 0.043) reduced, while testosterone (p = 0.014), testosterone:estradiol (T:E) ratio (p = 0.0005), freeT3 (p = 0.043), IGF-1 (p = 0.003), and cortisol awakening response (CAR) (p = 0.001) increased significantly. All basal parameters and early responses to ITT normalized, when compared to healthy athletes. Basal metabolic rate, fat oxidation, body fat, muscle mass, and hydration status had partial but non-significant improvements. Conclusion: After 12 weeks, athletes affected by actual OTS demonstrated substantial improvements, remarkably IGF-1, freeT3, CAR, testosterone, estradiol testosterone:estradiol ratio, CK and catecholamines, and early cortisol, early prolactin, and overall GH responses to stimulations.

MON-LB101 5-Year Data of an Aggressive Pharmacological Approach to Moderate and Morbid Obesity: Is Prevention of Bariatric Surgery Feasible in the Long Run?

Background: Maintenance of weight loss in patients that undergo weight loss interventions is highly challenging, irrespective of the type of approach to obesity (whether surgical, pharmacological, or non-pharmacological). We proposed a protocol of an aggressive clinical treatment for obesity aiming to prevent the need of bariatric surgery, in patients unwilling to undergo this procedure, by proposing a protocol that included the combination of different anti-obesity medications and non-pharmacological modalities, for longer duration, and with an active approach to prevent weight regain. Our initial 2-year data showed that 93% (40 of 43 patients) with moderate and morbid obesity were able to avoid the need of bariatric surgery, with concomitant improvements of the biochemical profile. However, whether these patients would maintain their successful rates after five years was uncertain. Our objective is to describe the efficacy and safety of a long term (5-year data) pharmacological and multi-modal treatment for moderate and severe obesity. Methods: The 40 patients that were successful in the two-year approach in our obesity center (Corpometria Institute, Brasilia, DF, Brazil) were enrolled. A long-term anti-obesity protocol was employed, with continuous or intermittent use of anti-obesity drugs, trimestral body composition analysis, psychotherapy, visit to a nutritionist every four months, and both resistance and endurance exercises at least four times a week. Body weight (BW), total weight excess (TWE), body fat, markers of lipid and glucose metabolism, liver function, and inflammation were analyzed. Subjects that dropped out were considered as weight regain. Therapeutic success for the 5-year follow-up included as the maintenance of &gt;20% loss of the initial BW loss, and no weight regain (or &lt; 20% of the initial weight loss). Results: A total of 27 patients (67.5%) were able to maintain the body weight, seven dropped out, and six regained more than 20% of the initial weight loss. Of these, 21 (77.8%) had significant further increase of muscle mass and decrease of fat loss, while 17 (63.0%) had further weight loss (p &lt; 0.05), compared to the 2-year data. Improvements on the biochemical profile persisted in all 27 patients, and had significant further improvements in 24 (88.9%) of these patients. Conclusion: The risk of weight regain five years after a weight loss treatment for obesity was significantly lower compared to previous literature, and comparable to the long-term outcomes of bariatric procedures. An aggressive, structured, and long-term clinical weight loss approach has been shown to be feasible, even for morbidly obese patients.