Anabolic steroids (also known as androgenic steroids) are synthetic derivatives of testosterone. Legal, as well as illegal use of anabolic steroids, is gaining popularity. There are two types of anabolic steroids: 1) 17 alpha alkyl derivatives: e.g., oxandrolone, oxymetholone, and fluoxymesterone; and 2) 17 beta ester derivatives: e.g., testosterone cypionate, testosterone enanthate, testosterone heptylate, testosterone propionate, nandrolone decanoate, nandrolone phenpropionate, and dromostanolone. Nandrolone phenpropionate is a C18 androgenic anabolic steroid and was one of the first anabolic steroids to be used as a doping agent by professional athletes in the 1960s. It was banned from the Olympics by the IOC in 1974. All anabolic steroids are DEA schedule III drugs.
FDA-approved indications for the use of anabolic steroids are primary hypogonadism, delayed puberty in boys (testosterone enanthate), hypogonadotropic hypogonadism (testosterone cypionate, enanthate, and undecanoate), gonadotropin and luteinizing hormone-releasing hormone deficiency, pituitary-hypothalamic axis dysfunction from various tumors, injury, and radiation. Other indications for the use of testosterone include primary testicular failure in patients with cryptorchidism, orchitis, testicular torsion, vanishing testis syndrome, previous history of orchiectomy, Klinefelter syndrome, chemotherapeutic agents, toxic damage from alcohol use and heavy metals.
Non-FDA approved indications of androgenic steroids include bone marrow stimulation in leukemia, aplastic anemia, kidney failure, growth failure, stimulation of appetite and muscle mass in malignancy and acquired immunodeficiency syndrome. Anabolic steroids users are sometimes used by athletes at all levels in sports such as bodybuilding, weightlifting, baseball, football, cycling, wrestling, and many others to improve their performance.
Endogenous androgen is responsible for the growth and development of the sex organs in men and maintaining secondary sex characteristics. Endogenous anabolic steroids such as testosterone and dihydrotestosterone and synthetic anabolic steroids mediate their effects by binding to and activating androgen receptors. In skeletal muscle, anabolic steroids regulate the transcription of target genes that control the accumulation of DNA in skeletal muscle required for muscle growth.
Anabolic steroids also upregulate and increase the number of androgen receptors, thus enabling increased training intensity, and thereby indirectly contributing to an increase in muscle size and strength. They also have a stimulatory effect on the brain through their diverse effects on various central nervous system neurotransmitters, antagonism of glucocorticoids, and stimulation of the growth hormone-insulin-like growth factor-1 axis.
Nandrolone decanoate and nandrolone phenpropionate are associated with the increased ratio of anabolic activity versus androgenic activity. Nandrolone decanoate is a slow acting anabolic steroid that was designed for the solitary purpose of increasing muscle mass. It acts by promoting nitrogen retention in muscles leading to an increase in muscle size and provide joint pain relief by promoting the synthesis of collagen and the enhancement of bone mineralization. Nandrolone phenpropionate also causes an increase in muscle growth, stimulation of appetite, and an increase in the production of red blood cells.
Dromostanolone is a synthetic anabolic steroid with anti-estrogenic properties and is five times more potent than methyltestosterone which is being used widely by bodybuilders to prepare for competition. It increases retention of nitrogen, phosphorus, and potassium, resulting in an increase of protein anabolism and a decrease in the catabolism of amino acids, leading to an increase in density and hardness of muscle.
Anabolic steroids are administered as oral pills, injections, creams or topical gels, and skin patches.
Medications Not Approved by FDA for Medical Use
Following are the adverse effects of anabolic steroids:
Testosterone cypionate is contraindicated in presence of severe renal, cardiac and hepatic disease, men with breast cancer and prostate cancer, venous thromboembolism, pregnant women or women who may become pregnant, breastfeeding women, hypersensitivity to any component of the formulation. The Endocrinology Society suggests that it may be judicious to avoid treatment with testosterone in men who have a history of myocardial infarction and stroke in the last 6 months.
Prior to initiation of treatment with testosterone, diagnosis of hypogonadism should be confirmed by measuring early morning testosterone level on two separate days. Lipid profile, hepatic function tests, hemoglobin, hematocrit, prostate-specific antigen and prostate exam in patients older than 40 years of age should be done prior to initiating treatment.
During treatment with anabolic steroids, lipid profile, hepatic function tests, hemoglobin, the hematocrit should be taken (at 3 to 6 months, then every year). Women treated with testosterone for breast cancer should be monitored for signs of virilization. Patients should be monitored for response to treatment with testosterone and also adverse effects three to six months after initiation of treatment and then every year, especially for cardiac adverse events.
Men greater than 40 years of age with baseline prostate-specific antigen (PSA) more than 0.6 ng/mL should have their PSA levels measured and a prostate examination at 3 to 6 months. Treatment should be withheld in men with a palpable prostate nodule or prostate-specific antigen more than 4 ng/mL and in patients who are at high risk of prostate malignancy with prostate-specific antigen more than 3 ng/mL.
Testosterone level should be measured midway between injections in testosterone enanthate and testosterone cypionate, and dose and frequency adjustments should be done to keep testosterone concentration between 400 ng/dL and 700 ng/dL (Endocrine Society 2010). Serum testosterone level should be measured two to eight hours after application and after fourteen days of starting the therapy or with dose titration in patients using a topical solution of testosterone.
Total serum testosterone should be measured periodically, starting from the first month after the initiation of therapy in patients using nasal testosterone gel and should be stopped if total testosterone is greater than 1050 ng/dL. Serum testosterone level should be measured approximately 14 days after initiation of therapy, in the morning, prior to application of transdermal testosterone, at the end of the dosing interval in testosterone pellets, and 4 to 12 weeks after initiation of treatment and prior to morning dose in patients using a buccal form of testosterone.
A multidisciplinary approach to anabolic steroids
There is no question that anabolic steroids do have a clinical role in patients with HIV, liver disease, renal failure, some malignancies and in burn patients. But today the problem with these agents is one of abuse. Despite legislation to limit empirical prescription and dispensing of these agents, these medications continue to be abused by athletes. To prevent anabolic drug abuse, the role of the nurse and pharmacist are critical. Athletes have to be educated about the potential harm from these drugs and that there are very sophisticated methods of detecting them in the blood and urine. Plus, athletes need to know that many anabolic steroids bought online are counterfeit and also contain additives, that may be toxic. The other problem is one of addiction to these agents and referral to a mental health counselor. In addition, the user must be told that the psychoactive effects of anabolic steroids can be deadly resulting in anger, suicidal thoughts, rage and extreme violence. Abuse of anabolic steroids is a problem at all levels of schooling and includes both genders. The physician, physician assistant, nurse, and pharmacist should encourage cessation of these agents and refer the patient to the appropriate specialist for treatment. (Level III)
When used appropriately, anabolic steroids can help with weight gain but one has to monitor the patient for adverse effects. In general, when used for short periods when indicated, the anabolic steroids can reverse the cachexia in a number of disorders. At the same time, healthcare workers should be fully aware that these drugs are abused and hence close monitoring is necessary.(Level III)