Liver Injury after Selective Androgen Receptor Modulator Intake: A Case Report and Review of the Literature

Abstract

Liver injury associated with selective androgen receptor modulators (SARMs) is an issue that has not been reported often. We report a case of a previously healthy 24-year-old male, who was referred to our hospital for severe jaundice with intense pruritus. He had previously taken the SARM Enobosarm (also known as Ostarine) for muscle-building purposes. Blood serum levels of total bilirubin exceeded 30 mg/dL with only a slight elevation of liver enzymes. Liver biopsy revealed isolated hepatocellular cholestasis (bland cholestasis) with limited inflammation or necrosis. Supportive treatment was begun in our hospital with molecular adsorbent recirculation system (MARS) albumin dialysis, as well as cholestyramine for pruritus relief. During therapy, bilirubin levels and symptoms regressed, and after five sessions of dialysis, the patient could be released from our clinic in a markedly improved clinical and laboratory condition. However, bilirubin parameters regressed slowly after this, reaching normal levels as late as six months after first intake of the compound. Exome-based genetic testing brought about no pathogenic variants for cholestatic liver disease in our patient. Nevertheless, three common heterozygous polymorphisms associated with an increased risk for intrahepatic cholestasis could be identified. Our case demonstrates that SARMs can cause severe liver injuries not prominently mentioned in safety data sheets. Therefore, these compounds constitute a potential danger to the user’s health. This holds especially true when taking SARMs without supervision by a medical professional, which should consist of a thorough monitoring of liver enzyme and bilirubin levels.

Zusammenfassung

Leberschäden im Zusammenhang mit selektiven Androgenrezeptormodulatoren (SARM) stellen eine wenig erforschte Nebenwirkung dieser Substanzklasse dar. Im Folgenden berichten wir von einem zuvor gesunden 24-jährigen Patienten, der uns zur Therapie bei schwerem Ikterus mit massivem Pruritus überwiesen wurde. Er hatte zuvor den SARM Enobosarm (auch bezeichnet als Ostarine) zu Zwecken des Muskelaufbaus eingenommen. Der Wert des Gesamtbilirubin war bei Aufnahme auf über 30 mg/dL gestiegen, gleichzeitig zeigte sich nur eine minimale Erhöhung der Leberenzyme. Eine Leberbiopsie erbrachte den Befund eines Leberschadens vom cholestatischen Typ im Rahmen einer reinen Cholestase ohne begleitende Entzündung. Unsererseits wurde eine Albumindialyse mit dem Molecular Adsorbent Recirculation System (MARS) sowie eine Cholestyramin-Therapie aufgrund des starken Juckreizes eingeleitet. Darunter kam es zu einer deutlichen Regredienz der Gesamtbilirubinwerte und der klinischen Symptomatik, woraufhin der Patient aus unserer Klinik entlassen wurde. Eine vollständige Normalisierung der Bilirubinwerte trat allerdings erst etwa sechs Monate nach der erstmaligen Einnahme des Präparats ein. Eine exombasierte genetische Untersuchung erbrachte keine Hinweise auf pathogene Varianten in Bezug auf cholestatische Lebererkrankungen. Allerdings konnten in unserem Falle drei häufige heterozygote Polymorphismen identifiziert werden, die das Risiko für eine intrahepatische Cholestase erhöhen. Unsere Kasuistik zeigt, dass die Einnahme dieser Androgenrezeptormodulatoren schwere Leberschädigungen hervorrufen kann. Diese Nebenwirkung wird häufig nicht in Sicherheitsdatenblättern erwähnt, obwohl durchaus schwerwiegende Risiken für die Gesundheit bestehen. Dies ist insbesondere der Fall bei Einnahme ohne eine professionelle medizinische Supervision, welche aus engmaschiger Kontrolle der Leberenzyme und Bilirubin bestehen sollte.

Keywords

Ostarine - Drug-induced liver injury - DILI - Cholestasis - SARM - Enobosarm - Anabolic androgenic steroids

Schlüsselwörter

Ostarine - Leberschaden - DILI - Cholestase - SARM - Enobosarm - anabole Steroide

Publication History

Received: 06 July 2023

Accepted after revision: 18 September 2023

Article published online:
23 October 2023

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