Hepatotoxicity Associated with Anabolic Androgenic Steroids Present in Over-The- Counter Supplements: a Case Series

With the aim of improving their physical performance, athletes and non-athletes have been using anabolicandrogenic steroids (AAS). Over the past several decades, there has been an increase in the prevalence of AAS use without adequate supervision or monitoring. We present three cases of AAS-related liver injury with the intention to discuss the use of nutritional supplements as a growing public health concern. Our three patients were able to obtain these "food supplements" containing AAS from health shops. We have shown with high level of evidence that the AAS were the cause of acute liver injury in these patients. All other causes of liver disease were excluded by laboratory evaluation and liver imaging. They all had a similar clinical picture with rapid development of fatigue, jaundice and pruritus. The first patient was on statin for his hyperlipidemia, but the clinical picture was not compatible with statin induced hepatotoxicity. He was on a stable dose and did not have a rise in liver tests with rechallenge. The third patient did consume alcohol in binges but the biopsy was not consistent with alcohol-induced injury. The liver biopsy in all three patients was suggestive of AAS-induced hepatotoxicity. (1) Finally, all three patients were young and relatively healthy and the liver panel results normalized gradually after cessation of the AAS. The aminotransferases in particular normalized according to their half-life after discontinuation of the insulting agent. Synthetic AAS that are not classified as controlled substances continue to fall outside the Food and Drug Administration (FDA) jurisdiction. They are still available in over-the-counter supplements and are a cause for serious hepatotoxicity in the United States. Stricter control of their use outside the medical necessity should be applied and healthcare providers should be aware of their potential harm.