Teaching slides on steroids in acute medical unit

Teaching slides on steroids in acute medical unit

1. AMU Teaching Shash

2. Case 1 A GP refers Mr. Pudzianowski, a 32yo Polish scaffolder with 2 months of lethargy, headaches and progressive peripheral oedema. His GP noted a new hypertension- 210/105 at the surgery. The man reports his tiredness has become unmanageable in the last few days and is affecting his ability to stay awake at work. On examination, you note well developed musculature, exquisite tenderness around his nipples, and peripheral oedema to the shins. Bloods, including BNP, are unremarkable aside from a moderate dyslipidaemia . ECG NAD.

3. Case 1 -OSA secondary to rapid intentional weight gain -HTN, gynecomastia, peripheral oedema and dyslipidaemia secondary to (poorly managed) anabolic steroid use

4. Performance enhancing drugs in the acute medical patient

5. Learning objectives Awareness of common PEDs and associated pharmaceuticals used in strength sports/bodybuilding Some ways PED use may affect the care of AMU patients

6. Common PEDs

7. Common PEDs Testosterone and it’s derivatives Direct anabolic and androgenic effects Usually “pinned” IM- frequency depends on the ester Selective androgen receptor modulators - ostarine , bicalutamide SARMs are non-steroidal testosterone receptor ligands Increasingly used by younger (teenage) boys as these are orally active and so don’t require pinning Shuts down HPG axis, but not a substrate for aromatase so crashes E2 if not used responsibly

8. Common PEDs Insulin and IGF-1 Main anabolic hormone of the body. Low insulin levels drive catabolisis . “ Hyperinsulinaemic clamp”. IGF-1 has direct hypertrophic effect through same pathway as HGH. Thyroxine HGH Direct hypertrophic effect on all organs excluding the brain. Stimulates IGF-1 release.

9. Common PEDs Clenbuterol B2 agonist. Not directly anabolic, but ergogenic effect like ephedrine/amphetamines. Used extensively by female athletes as it is not androgenic.

10. Common PEDs Creatine Involved in phosphorylation of ADP to ATP. Improves anaerobic performance. Widely used- often mixed into protein supplements or pre-workouts and available in every large supermarket. Very safe in normal dosing. Pre-workouts- caffeine, amphetamines, GTN

11. Associated drugs Aromatase inhibitors- anastrozole, exemestane To prevent excessive aromatization and so gynecomastia, water retention, hypertension. Also can be used to aid PCT. SERM- tamoxifen, clomifene , raloxifene Primary method of PCT. Reduces effect of E2 on pituitary, so stimulates LH/FSH release and more rapid return of physiological HPG axis.

12. Associated drugs HcG LH mimetic. Acts on Leydig cells and preserves testicular size and function (fertility and test production). Diuretics Anti-hypertensives and metformin

13. Case 2 26yo M presents with 1 month history of worsening global pruritus and a burning sensation in his hands and feet. He takes apixaban following an unprovoked PE, and metformin which he sources privately as he was advised to do so by a fitness influencer on YouTube. On examination you note the appearance of his conjunctiva as across and lipodystrophic areas on his thighs. What is the diagnosis?

14. Case 3 You clerk a 52-year-old fireman on AMU who has presented with pyelonephritis. As an aside, he states he has had an aching pain in his left thigh that is worse at night. XR as across. The patient admits to having supplemented high-dose exogenous testosterone for circa 15 years, though for the last 7 years he has only used TRT as prescribed by his online GP. What does the XR show and what diagnosis am I trying to lead you towards?

15. Case 4 17yo M presents with 1 week hx fever, sore throat, arthralgia and headache. The patient’s palate is pictured across. His older friends all take testosterone and convinced him to try a cycle with them, which they all started 4 weeks ago.

16. Case 5 30yo F Strongwoman presents with mild confusion, jaundice, pruritus, and nausea. Pale stool and dark urine. ALT normal, ALP >2x normal. Viral, autoimmune and inherited liver disease ruled out. MRCP did not show any biliary tract obstruction. Why is this lady jaundiced? What might treatment involve?

17. Lastly, You see the man with polycythaemia in a follow up clinic. Through your effective motivational interviewing skills, you convince him of the benefits of abstinence from exogenous steroids. He is hesitant to stop cold turkey, however, and would like your help to come off his cruise dose with minimal side effects. What would you advise this man?

18. Lastly, Week 1-4:  4-week tapered course TRT. Simultaneous administration of a SERM (clomiphene). Week 5-8:  If the patient has had either a poor gonadotropin response or a poor T response, the authors commence a 4-week course of hCG (1,000–3,000 IU, 3 times per week) while continuing daily treatment with a SERM at the initial starting dose. If a patient develops gynecomastia while on hCG , Tamoxifen or Anastrazole may be commenced. If the total serum T remains low and the patient continues to be symptomatic:  primary testicular failure is likely. These patients will require a longer duration of TRT to avoid permanent ASIH. If appropriately increased serum T levels are observed:  the SERM may be reduced to 50% of its starting dose at 10 weeks of treatment and continued through weeks 12–16 or until target serum T level is achieved.

19. Any questions?