Seattle Treatment Education Project (STEP) Perspective, Vol. 5, No. 2 - July 1993 * 127 Broadway E. Ste 200 Seattle, WA 98102
Wayne Dodge, MD

Steroids comprise an important class of biologic compounds in the body. Cholesterol is a steroid. Cortisol, which is the basic well-being hormone of the body, is a corticosteroid. It, and medications like it such as prednisone, have strong anti-inflammatory properties. They are useful in conditions such as acute PCP or HIV related persistant oral/esophageal ulcerations but are also immune suppressing in high doses. Hormones and drugs called mineralocorticosteroids govern how the kidneys handle the salts in the blood and thereby maintain blood pressure. The sex hormones are also steroids and include testosterone - the primary anabolic steroid in humans.

Synthetic anabolic steroids have been widely used since the 1940s to treat (often without much data) a variety of chronic infections, anemic conditions, muscle wasting diseases and protein deficiencies.1 However, with their use and abuse by the muscle culture of the 1980s, anabolic steroids have fallen into disrepute and now require the same restrictive pharmacy practices as Schedule II narcotics. The effect of anabolic steroids is to increase the body's ability to incorporate protein into muscle. They also often have a stimulatory psychological effect, including libido (sex drive), that can sometimes result in outright aggression. Most of the currently available anabolic steroids are also androgenic (producing male characteristics, such as beard and chest hair growth, deeper voice and acne). This limits their usefulness in women, although testosterone in lower doses has been used with some success in females who have decreased libido associated with menopause or removal of the ovaries. Another significant side effect of anabolic steroids is a tendency to produce an inflammation of the liver (hepatitis) when taken orally. For older men, significant side effects include more rapid enlargement of the prostate, causing difficulty with urination and the possibility of accelerating a previously undetected and quiescent prostate cancer.

It is known that testosterone levels decrease in HIV infected men as the disease progresses2,3,4,5,6,7, although not all studies have agreed with this finding8,9. This decrease in testosterone level has been correlated with both CD4 lymphocyte depletion and weight loss7. It is also known that reduced libido and increased incidence of impotence are frequent complaints in males with AIDS.3 The problem for health care practitioners is that during chronic severe illnesses endocrine systems often show abnormalities that are caused by the illness but are not necessarily the cause of the illness. A prime example would be tests for thyroid which may be abnormal during a severe illness, although treating the individual on the basis of these lab tests does not help the individual (and may cause harm). An additional complication is that an individual's testosterone level may fall into the normal range for most laboratories while more sophisticated tests would indicate abnormality. This leaves the clinician and the individual in a dilemma.

Studies now in progress are using currently available synthetic anabolic steroids - nandrolone (trade name Durabolin, made by Organon) and oxandrolone (made by Gynex) - for both constitutional symptoms (fatigue/weakness) and muscle wasting. It is hoped the results of these studies will provide information on the utility of this approach. Until this information is available, the following would be a practical solution.

If an HIV infected individual has had significant weight loss, significant fatigue, or muscle wasting (especially proximal--e.g., thigh and upper arm), and particularly if associated with a significant decrease in libido and erections (with attention paid to the lack of a morning or "piss" hard- on), a serum testosterone level should be obtained. If it is in the low or low normal range (less than 300 ng/dl) then a trial of testosterone therapy could be tried. The individual and the clinician should decide what result would constitute a successful trial - e.g., weight gain of 15 pounds, a 30% improvement in sense of well-being, a successful erection once a week, etc. Then a testosterone (depo-testosterone) injection of 200 mg every two weeks can be given over two to three months with periodic evaluation. If the treatment is "successful," continued use of the medication is probably warranted. If not, the individual's own hormonal system will rapidly readjust when the medication is stopped. Individuals can easily be taught to do their own injections. The synthetic anabolic steroids have more potency, but have the drawback that their use is closely watched by the State Board of Pharmacy. This means that the drugs are less available and physicians are unaccustomed to prescribing them and will probably remain wary until the above studies are completed.

References:

1. Anon. Androlgenic steroids. AIDS Treatment News #150

2. Accetturi,C. et al, Gonadol hormone levels and testicular histology in AIDS. Int Conf AIDS. 1989 Jun 4-9; 5:266(abstract no.M.B.P.266)

3. Klauke,S. et al, Hypogonadism in male patients with AIDS. 1990 Jun 20- 23;6(2):209(abstract no. F.B.525)

4. Christeff,N. et al, Evidenece for changes in adrenal and testicular steroids during HIV infection. J. Acquir Immune Defic Syndr. 1992;5(8):841- 6

5. Villette,JM. et al, Circadian variations in plasma levels of hypophyseal, adreocortical and testicular hormones in men infected with human immunodeficiency virus. J Clin Edocrinol Metab. 1990 Mar; 70(3):572-7

6. Croxson, TS. et al, Changes in the hypothalamic-pituitary-gonadal axis in human immunodeficiency virus infected homosexual men. J Clin Edocrinol Metab. 1989 Feb;68(2):317-21

7. Dobs,AS; Dempsey,MA; Ladenson,PW; Polk,BF. Endocrine disorders in men infected with human immunodeficiency virus. Am J Med 1988 Mar;84(3Pt2):611- 6.

8. Villete,JM. et al. Modifications in circadian rhythms of plasma levels of cortisol,ACTH, Conf testostone, and adrenal androgens (DHEA and DHEA-S) in HIV-infected male patients. Int conf AIDS 1989 Jun 4-9;5:266(abstract no.M.B.P.269)

9. Brockmeyer,NH; Mertins,L; Goos,M. Andrological features in HIV-1 infected patients.Int Conf AIDS1989 Jun 4-9;5:893(abstract no. E.548)A A K C V C
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