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Abstract
Background: The recreational use of anabolic-androgenic steroids (AAS) has reached alarming levels among healthy people. However, several complications have been related to consumption of these drugs, including liver disorders. Objective: To evaluate the prevalence of liver injuries in young Brazilian recreational AAS users. Methods: Between February/2007 and May/2012 asymptomatic bodybuilders who were ≥18 years old and reported AAS use for ≥6 months were enrolled. All had clinical evaluations, abdominal ultrasound (AUS), and blood tests. Results: 182 individuals were included in the study. The median age (interquartile range) was 26.0 years (22.0–30.0) and all were male. Elevated liver enzyme levels were observed in 38.5% (n = 70) of AAS users, and creatine phosphokinase was normal in 27.1% (n = 19) of them. Hepatic steatosis was observed by AUS in 12.1% of the sample. One individual had focal nodular hyperplasia and another had hepatocellular adenoma. One case each of hepatitis B and C virus infection was found. A diagnosis of toxic liver injury was suggested in 23 (12.6%) AAS users without a history of alcohol or other medications/drugs consumption, or evidence of other liver diseases. Conclusions/Importance: Young Brazilian recreational AAS users presented a wide spectrum of liver injuries that included hepatotoxicity, fatty liver, and liver neoplasm. They also presented risk factors for liver diseases such as alcohol consumption and hepatitis B and C virus infection. The results suggest that the risk of AAS use for the liver may be greater than the esthetic benefits, and demonstrate the importance of screening AAS users for liver injuries.
THE AUTHORS
Paulo Adriano Schwingel, PhD, received his bachelor degree in physical education at Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil. He has received the MSc and PhD degrees in Medicine and Health consecutively in the Bahia's School of Medicine (FMB) at Federal University of Bahia (UFBA), Salvador, BA, Brazil. Currently, he is Adjunct Professor in Department of Nutrition at University of Pernambuco (UPE), Petrolina, PE, Brazil, and Sports Physiologist in the Brazilian Paralympic Swimming Team at Brazilian Paralympic Committee (CPB). Schwingel is also a leader of the Human Performance Research Group certified by Brazilian National Council of Scientific and Technologic Development (CNPq). His primary interests include human performance, sports physiology, performance enhancing substances, and health promotion.
Helma Pinchemel Cotrim, PhD, is a medical doctor and Associate Professor of Gastroenterology and Hepatology in the Bahia's School of Medicine (FMB) at Federal University of Bahia (UFBA), Salvador, BA, Brazil. She holds a PhD in Medicine at UFBA and she completed her Postdoctoral in Hepatology at Stanford University, CA, USA. Currently, she is a leader of the Research Group to Study Nonalcoholic Steatohepatitis (NASH) certified by Brazilian National Council of Scientific and Technologic Development (CNPq). Her primary interests include hepatology and gastroenterology, particularly steatosis, and steatohepatitis.
Crimério Ribeiro dos Santos, Jr., BPhEd, received his bachelor degree in physical education at Social School of Bahia (FSBA), Salvador, BA, Brazil. He integrated the Research Group to Study Nonalcoholic Steatohepatitis (NASH) from 2009 to 2014, and currently is Personal Trainer. His primary interests include exercise training, sports physiology, metabolism, and resistance training in health and disease.
Adriano Oliveira dos Santos, BPhEd, received his bachelor degree in physical education at Social School of Bahia (FSBA), Salvador, BA, Brazil. He integrated the Research Group to Study Nonalcoholic Steatohepatitis (NASH) from 2010 to 2014, and currently is Fitness Coach. His primary interests include exercise physical training, sports and exercise physiology, and resistance training in health and disease.
Antônio Ricardo Cardia Ferraz de Andrade, MSc, received his medical degree in the Medicine School at Federal University of Minas Gerais (UFMG), Belo Horizonte, MG, Brazil. He has received the MSc degree in Medicine and Health in the Bahia's School of Medicine (FMB) at Federal University of Bahia (UFBA), Salvador, BA, Brazil. Currently, he is Medical Researcher and Philosophy doctoral candidate in the FMB at UFBA. His primary interests include hepatology, gastroenterology, and public health.
Marcos Vinicius Vilas Boas Carruego, MD, received his medical degree in the Bahia's School of Medicine (FMB) at Federal University of Bahia (UFBA), Salvador, BA, Brazil. Currently, he is Medical Researcher in the Research Group to Study Nonalcoholic Steatohepatitis (NASH). His primary interests include hepatology, gastroenterology, and clinical medicine.
Cláudio Cesar Zoppi, PhD, received his bachelor degree in physical education at State University of Campinas (UNICAMP), Campinas, SP, Brazil. He has received the MSc and PhD degrees in Functional and Molecular Biology consecutively in the Institute of Biology (IB) at UNICAMP. Currently, he completed her Postdoctoral in Physiology at UNICAMP and is Teaching and Research Assistant at UNICAMP. His primary interests include exercise training, metabolism, obesity, skeletal muscle, and pancreatic islets.
GLOSSARY
Alcohol liver disease (ALD): ALD refers to liver damage caused by chronic alcohol consumption. It covers a range of conditions and associated symptoms. ALD does not usually cause any symptoms until the liver has been severely damaged. There are three main stages of ALD: alcoholic fatty liver disease (drinking a large amount of alcohol, even for only a few days, can lead to a build-up of fats in the liver), alcoholic hepatitis (which occurs when the individuals have a high alcohol consumption for many years); and cirrhosis (the final stage of ALD).
Anti-hepatitis C virus (anti-HCV) antibody test: This serum marker is used to identify individuals infected with hepatitis C virus (HCV). When the body is infected with a virus, it produces antibodies to fight the virus off. The hepatitis C antibody test looks for antibodies that the body produces in response to the presence of HCV. HCV infects the liver, often causing inflammation and damage. It is often transmitted by sharing infected syringes or needles used to inject drugs or by having unprotected sex.
Drug-induced liver diseases: Drug-induced liver diseases are diseases of the liver that are caused by physician-prescribed medications, over-the-counter medications, vitamins, hormones, herbs, illicit or recreational drugs, and environmental toxins. When drugs injure the liver and disrupt its normal function, symptoms and signs of liver disease develop, along with abnormal blood tests. Abnormalities of drug-induced liver diseases are similar to those of liver diseases caused by other agents such as viruses and immunological diseases. For example, drug-induced hepatitis (inflammation of the liver cells) is similar to viral hepatitis.
Focal nodular hyperplasia (FNH): FNH is a benign tumor of the liver. It is the second most common tumor of the liver, surpassed in prevalence only by hepatic hemangioma. It is not of vascular origin, is usually asymptomatic, rarely grows or bleeds, and has no malignant potential. FNH is seen in both sexes and throughout the age spectrum, although it is found predominantly in women (in a ratio of 8 or 9:1) between the ages of 20 and 50 years.
Hepatitis B surface antigen (HBsAg) test: This test looks for hepatitis B surface antigens in the blood to test for a recent or long-standing infection from the hepatitis B virus (HBV). HBV has proteins called antigens on its surface that cause the immune system to make antibodies. Hepatitis B surface antigens can be found in blood within 12 weeks from the start of the infection. They are one of the earliest signs of a HBV infection, and they are also present during chronic, or long-term, infection. HBV is spread through blood, seminal fluid, and vaginal secretions. The virus causes an infection in the liver. In most cases, this virus clears up on its own within six months, but in 6% to 10% of adults and 25% to 50% of children, the virus does not go away. This is called having a chronic infection. It may lead to liver cell damage, scarring or cirrhosis, or liver cancer.
Hepatocellular adenoma (HCA): HCA is also known as hepatic adenoma or liver cell adenoma. HCA is an uncommon benign liver tumor that is hormone-induced. The tumors have a tendency to hemorrhage and must be differentiated from other focal liver lesions. They are tumors of presumably epithelial origin and occur in less than 0.004% of the population at risk.
Non-therapeutic use of anabolic-androgenic steroids: The nonmedical uses of testosterone or its derivative substances or the use of several anabolic steroids simultaneously without a physician's prescription beyond the physiological concentration.
Toxicant-associated fatty liver disease (TAFLD): The criteria for TAFLD include history of alcohol intake <20 g/day; history of AAS use for >2 years; hepatic steatosis on abdominal ultrasound and/or levels of aminotransferases elevated by at least three-fold with normal CPK levels; and exclusion of metabolic syndrome, obesity, dyslipidaemia, diabetes mellitus, use of any other drugs or medications, and other liver diseases (hepatitis B and C viruses, hemochromatosis and autoimmune hepatitis).
Notes
1 The illicit use of supraphysiological doses of anabolic–androgenic steroids for cosmetic purposes aims to improve physical appearance by improving the volume and shape of muscles, not to improve physiological/performance measures (strength, power, speed, and endurance). Low body fat and well-developed muscles are attributes associated with the use of nontherapeutic doses of testosterone or its derivatives. The emphasis for this group of steroid users is on body proportions for esthetic reasons, aiming to maintain a small waist and increase the breadth of the shoulders to create a much sought-after inverted V-shape.
2 A disease is considered asymptomatic if a patient is a carrier for a disease or infection but experiences no symptoms. A condition might be asymptomatic if it fails to show the noticeable symptoms with which it is usually associated.