Can anabolic steroids be given to a critically ill patient on hemodialysis (HD) in the ICU (Intensive Care Unit)?

Anabolic Steroids in ICU Patients on Hemodialysis with ICU-Acquired Weakness

Anabolic steroids may be beneficial in critically ill patients on hemodialysis with ICU-acquired weakness (ICUAW) to improve nutritional parameters and muscle strength, but should be used with careful monitoring of potential side effects.

Rationale for Anabolic Steroid Use in ICUAW

• ICUAW in critically ill patients is associated with significant functional impairment and is exacerbated by several factors including protein catabolism, reduced anabolism, and testosterone deficiency 1
• Patients on hemodialysis experience increased protein breakdown and amino acid losses during dialysis treatments, further contributing to muscle wasting 1
• Critically ill patients on hemodialysis are at high risk for malnutrition due to multiple factors including inflammation, hormonal changes, metabolic acidosis, and dialytic treatment 1

Evidence Supporting Anabolic Steroid Use

• Nandrolone decanoate has been shown to significantly improve nutritional parameters in hemodialysis patients, including increased serum albumin levels and dry weight 2
• In hemodialysis patients, anabolic steroids combined with resistance exercise training produced significant increases in lean body mass and quadriceps muscle cross-sectional area 3
• Case reports suggest functional improvements in muscle strength when anabolic steroids are used in critically ill patients with profound critical illness myopathy and weight loss 4

Dosing and Administration

• For hemodialysis patients, nandrolone decanoate has been used at doses of 100 mg intramuscularly for women and 200 mg intramuscularly for men weekly 3
• Alternative dosing regimens include 100 mg intramuscularly every 2 weeks or 25 mg intramuscularly weekly 2
• Treatment duration in studies ranged from approximately 3 months (12 weeks) 3

Nutritional Considerations

• Anabolic steroids should be used as part of a comprehensive nutritional approach that includes adequate protein intake 1
• Protein requirements for critically ill patients on hemodialysis are higher than standard requirements, with recommendations of 1.2-2.1 g/kg/day based on protein catabolic rate 1
• Intradialytic parenteral nutrition (IDPN) may be considered as a complementary approach for malnourished patients on hemodialysis who fail to respond to oral nutritional supplements 1

Monitoring and Potential Complications

• Monitor for androgenic side effects, though these are typically minimal and well-tolerated with nandrolone decanoate 5
• Be aware of potential serious complications including supraventricular tachycardia and exacerbation of acute kidney injury, though these are rare 6
• Regular assessment of nutritional parameters including serum albumin, dry weight, and muscle strength is recommended 2
• Monitor hematocrit levels, as anabolic steroids may increase hematocrit and potentially allow for reduction in erythropoietin dosing 2, 5

Patient Selection

• Best candidates include patients with:
  • Documented malnutrition (albumin <3.5 g/dL) 1
  • Significant muscle wasting despite adequate nutritional support 4
  • Stable hemodynamic status 4
  • Patients in the recovery phase of critical illness 4

Contraindications and Cautions

• Use with caution in patients with:
  • Unstable cardiovascular disease 6
  • History of thromboembolic events 6
  • Severe liver dysfunction 6
  • Pre-existing delirium or at high risk for delirium, as steroids can induce or worsen delirium 7, 8

Integration with Other Therapies

• Combine anabolic steroid therapy with resistance exercise training when possible for additive effects on muscle mass and strength 3
• Ensure adequate protein and caloric intake through enteral or parenteral nutrition as appropriate 1
• Early mobilization and physical rehabilitation should be implemented concurrently 1