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Thomas O’Connor, MD Board Certified Internal Medicine Clinical Instructor of Medicine University of Connecticut School of Medicine   October 25, 2016 Dear Editor: “Today,... Steroid Addiction

Thomas O’Connor, MDDoctor Thomas J. O'Connor MD

Board Certified Internal Medicine

Clinical Instructor of Medicine

University of Connecticut School of Medicine

 

October 25, 2016

Dear Editor:

“Today, the US Federal Drug Administration (FDA) approved class-wide labeling changes for all prescription testosterone products, adding a new Warning, and updating the Abuse and Dependence section to include new safety information from published literature and case reports regarding the risks associated with abuse and dependence of testosterone and other AAS (anabolic androgenic steroids).” (Medscape, Oct 25, 2016)

As a physician who has been treating men who have used or are using AAS since 2005, I am all too familiar with the psycho-endocrinal side effects of these drugs, notably anabolic steroid induced hypogonadism (ASIH), a form of hypogonadism which, although recognized by experts as unique to AAS users, (Rhanema et al, 2014) is not discussed in the FDA warning content. This is a serious omission, as it is this form of hypogonadism which is the primary cause of dependence and addiction in 15-30% of AAS users. (Brower, 2009)

I applaud the FDA’s long overdue recognition of the dangers inherent in AAS–dangers already known to veteran users, but tragically unknown to the younger users–including women– who are the fastest growing user group. However, I believe there is still much for our regulatory and professional agencies to do if we are to address this crisis fully. For example, it is critical that all physicians as well as potential users be made aware that ASIH is not only the primary and most dangerous side effect of AAS use,  but it is the single effect which makes withdrawal and attempts to cease AAS use the most difficult, and for some users the most dangerous.(Brower, 2009)  Noting this,  an Endocrine Society study group led by Dr. Shalendar Bhasin of Harvard concluded that all physicians needed to become more knowledgeable about these drugs, how they are used, and specifically how their side effects disrupt withdrawal and require targeted medical protocols to promote cessation. (Canavan, 2013)Anabolic Steroid Induced Gynecomastia

What most physicians must understand is that applying what they already know about diagnosing and treating hypogonadism in the general low T population is not sufficient to safely and effectively treat this unique form of hypogonadism in AAS users. For example, relying solely on lab numbers to make the initial decision to treat a symptomatic AAS patient seeking help with withdrawal and cessation can be tantamount to inappropriate denial of treatment. That is, the AAS patient presenting with significant depressed mood and poor libido–the hallmarks of AAS withdrawal–may have high-to-extremely high lab numbers, reflecting the amount of exogenous testosterone still in his system because of where he is in his steroids cycle. Requiring him to crash, without supportive medications, to what would be the predictably low endogenous testosterone levels caused by AAS use, is unsafe, unethical, and unnecessary.  Safe, effective withdrawal protocols, including weaning with tapered doses of physiological testosterone until restoration of the body’s ability to produce its own testosterone, have been reported by a number of experts. (Rahnema et al, 2014; Pope & Brower, 2008; Talih et al, Cleveland Clinic, 2007; Hochberg et al, 2003; Spratt, 2012; Zitzmann & Nieschlag, 2000)

I can testify to the many thousands of men who have now benefited from these recommended protocols. Men who have come safely through withdrawal, and on to subsequent cessation of AAS use–a goal which they had been unable to achieve on their own. However, even with treatment, restoration of the body’s ability to produce its own testosterone may be prolonged, or may not ever occur due to HPT damage caused by steroid abuse. (Kanayama et al, 2015; Stevens et al, 2011) In the latter event, these patients may require TRT, perhaps for life.

 REFERENCES

Brower, KJ.”Anabolic androgenic steroid abuse and dependence in clinical practice”, Physician Sports Medicine 2009; 37:131-40

Pope G & Brower, KJ. “Treatment of anabolic-androgenic steroid related disorders”, Chapter 17, The American Psychiatric Publishing Textbook of Substance Abuse Treatment, ed. Marc Galanter & Herbert Kleber, 2008

Canavan, N. “Endocrine society pumped up to raise steroid abuse awareness”, Medscape, Dec 17, 2013

Hochberg, A et al. “Endocrine withdrawal syndromes”, Endocrine Reviews, Aug 2003 (4)z;523

Kanayama G et al. “Prolonged hypogonadism in males following withdrawal from anabolic androgenic steroids:an underrecognized problem”, Addictions, Feb 2015

Rahnema C et al. “Anabolic steroid induced hypogonadism: diagnosis and treatment”, Fertil Steril Vol 101, No.5 May 2014

Spratt, D. “Considering tapering testosterone replacement in certain patients”, Endocrine Reviews September, 2012

Stevens, et al.”Persistent primary hypogonadism associated with anabolic steroid abuse”, Fertil Steril May, 2011

Talih, F et al. “Anabolic steroid abuse: psychiatric and psychological costs”, Cleveland Clinic Journal of Medicine May, 2007

Zitzmann, M & Nieschlag, E. “Hormone substitution in male hypogonadism, Molecular and Cellular Endocrinology 161 (2000) 73-88

 

Thomas O’Connor, MD

Board Certified Internal Medicine

Clinical Instructor of Medicine

University of Connecticut School of Medicine

www.thomasoconnormd.com

www.metabolicdoc.com

Office Phone #: 860.904.6779

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