What is the medical plan of care for a patient with a history of anabolic steroid use?

Medical Plan of Care for Patients with History of Anabolic Steroid Use

Patients with a history of anabolic androgenic steroid (AAS) use require comprehensive cardiovascular risk assessment and monitoring, as AAS use is associated with substantially increased risk of myocardial infarction, cardiomyopathy, heart failure, and venous thromboembolism, with effects persisting even after discontinuation. 1, 2

Initial Assessment and Risk Stratification

Cardiovascular Evaluation

• Obtain detailed AAS exposure history including specific agents used, cumulative duration of use, dosages, route of administration (oral vs. injectable), time since last use, and whether currently using 3
• Screen for cardiovascular symptoms including chest pain, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, palpitations, syncope, and lower extremity edema 3
• Assess for thrombotic events by evaluating for symptoms of deep vein thrombosis (pain, edema, warmth, erythema in lower extremities) and pulmonary embolism (acute shortness of breath), as AAS users have 2.42 times increased risk of venous thromboembolism 4, 1

Physical Examination Priorities

• Measure blood pressure using proper technique (bladder encircling ≥80% of arm length, validated electronic device, at least 2 readings separated by time, additional readings if variance >10 mm Hg) to detect hypertension, which is common with chronic AAS use 3
• Cardiac examination for murmurs, irregular rhythm, jugular venous distension, and signs of heart failure 3
• Examine for cushingoid features including abdominal striae, which may indicate concurrent or past corticosteroid use 3
• Check for gynecomastia, which frequently develops with AAS use 4
• Assess for edema, particularly lower extremity, as sodium and water retention is common 4

Laboratory and Diagnostic Testing

Essential baseline testing includes:

• Lipid profile (total cholesterol, HDL, LDL, triglycerides) as AAS cause concomitant elevations of LDL and decreases of HDL, increasing coronary artery disease risk 5
• Fasting glucose and hemoglobin A1c to assess for glucose intolerance and diabetes mellitus, which are associated with AAS use 3, 6
• Comprehensive metabolic panel including electrolytes, renal function (creatinine, BUN), and liver function tests (AST, ALT, bilirubin, alkaline phosphatase) to detect hepatotoxicity 4, 6
• Complete blood count to assess for polycythemia 3
• Testosterone level to determine if hypogonadism is present from suppression of endogenous production 3
• Urinalysis with dipstick for proteinuria to screen for renal disease 3

Cardiac imaging is indicated based on risk:

• 12-lead ECG to assess for left ventricular hypertrophy, conduction abnormalities, and arrhythmias 3

• Transthoracic echocardiography is advisable for all patients with history of prolonged AAS use to evaluate for: 2

  • Left ventricular systolic dysfunction (reduced ejection fraction, mean 52% in users vs. 63% in non-users)
  • Diastolic dysfunction (reduced early relaxation velocity)
  • Pathological left ventricular hypertrophy vs. physiological athlete's heart
  • Cardiomyopathy (8.90 times increased risk in AAS users) 1

• Coronary computed tomography angiography should be considered in patients with prolonged cumulative AAS exposure, as lifetime AAS dose is strongly associated with coronary atherosclerotic burden (increased plaque volume correlating with duration of use) 2

Cardiovascular Risk Management

Primary Prevention Strategies

• Aggressive lipid management with statin therapy targeting LDL <70 mg/dL given the accelerated atherosclerosis risk 5, 2
• Blood pressure control to target <130/80 mm Hg using ACE inhibitors or ARBs as first-line agents 3
• Antiplatelet therapy with aspirin 81 mg daily should be considered given the enhanced pro-thrombotic state and activated platelet aggregability in AAS users 5
• Counsel on lifestyle modifications including weight loss if overweight/obese, regular aerobic exercise (not resistance training focused), smoking cessation, and alcohol moderation 3

Monitoring for Complications

• Screen for arrhythmias as AAS users have 2.26 times increased risk; consider ambulatory ECG monitoring if palpitations or syncope present 1
• Monitor for heart failure symptoms given 3.63 times increased risk in AAS users 1
• Assess for acute coronary syndrome risk as AAS users have 3.00 times increased risk of myocardial infarction and 2.95 times increased risk of requiring percutaneous coronary intervention or coronary artery bypass graft 1

Endocrine and Reproductive Assessment

Hypogonadism Evaluation

• If testosterone deficiency confirmed (total testosterone <300 ng/dL with symptoms), exogenous testosterone therapy should NOT be commenced for 3-6 months after last AAS use to allow recovery of endogenous production 3, 4
• For men desiring fertility, use aromatase inhibitors, human chorionic gonadotropin, or selective estrogen receptor modulators rather than exogenous testosterone, as testosterone therapy interrupts spermatogenesis and causes oligospermia or azoospermia 3
• Target testosterone levels in middle tertile of normal range (450-600 ng/dL) if replacement therapy eventually indicated 3
• Never prescribe alkylated oral testosterone (e.g., methyltestosterone) due to hepatotoxicity risk 3

Hepatic Monitoring

• Assess for peliosis hepatis and hepatic neoplasms including hepatocellular carcinoma, which are associated with prolonged high-dose androgen use 4
• If cholestatic hepatitis with jaundice appears or liver function tests become abnormal, discontinue any ongoing androgen therapy and determine etiology 4
• Monitor liver function tests every 3-6 months in patients with history of prolonged AAS use 6

Psychiatric and Behavioral Health

• Screen for psychiatric symptoms including mood swings, anxiety, depression, psychosis, and aggressive behavior, which may occur during use or after withdrawal 6
• Assess for ongoing substance abuse including concurrent use of cocaine, amphetamines, or other performance-enhancing drugs 3
• Evaluate for body dysmorphia and muscle dysmorphia, which often drive continued AAS use 7

Musculoskeletal Considerations

• Examine for tendon ruptures and musculoskeletal injuries, which are more common in AAS users 6
• In adolescents or young adults with history of AAS use, assess bone age if growth plates potentially affected, as androgen treatment may accelerate bone maturation without compensatory linear growth, compromising final adult height 4

Ongoing Surveillance

Establish regular follow-up schedule:

• Every 3 months initially for cardiovascular risk factor monitoring (blood pressure, lipids, glucose) 3
• Annual echocardiography for patients with documented cardiac dysfunction or prolonged AAS exposure history 2
• Repeat coronary imaging every 3-5 years in high-risk patients (prolonged cumulative AAS use, multiple cardiovascular risk factors) 2
• Liver function tests every 6 months for first 2 years after cessation 4

Patient Education and Counseling

• Inform patients that cardiovascular risks persist even after AAS discontinuation, with structural cardiac changes and atherosclerotic burden potentially irreversible 1, 2
• Counsel regarding the substantially increased mortality risk associated with AAS use 1
• Advise against resumption of AAS use under any circumstances given the dose-dependent relationship between cumulative exposure and cardiovascular disease 2
• Discuss fertility implications if future conception desired, as recovery of spermatogenesis may take 6-12 months or longer after cessation 3