Case Presentation: A previously healthy 38-year-old man presented with 8 days of intermittent colicky RUQ pain and jaundice. He denied any OTC or illicit drug use but did report daily alcohol use. On admission HAV, HBV, HCV, and HIV 1 & 2 screening, urine drug screen, and autoimmune workup were negative. Ceruloplasmin, serum copper, serum iron, and ferritin were within normal limits. Imaging did not reveal signs of obstruction. AST 55 U/L, ALT 64 U/L, alkaline phosphatase 102 U/L, total bilirubin 11.9 mg/dL and INR of 1.3; a pattern consistent with drug induced liver injury (DILI). After repeated questioning he admitted using RAD140 (Testalone) which is an experimental selective androgen receptor modulator (SARM) he obtained illicitly online. His cholestatic liver injury worsened with bilirubin peaking at 27 mg/dL then stabilizing. Liver biopsy revealed bland cholestasis with no features of alcoholic hepatitis. He was treated with n-acetylcysteine until stabilization and ursodiol which was continued at discharge. Over a month later his bilirubin remains above 10 mg/dL.
Discussion: The typical pattern of anabolic steroid induced DILI is mildly elevated transaminases and alkaline phosphatase (no more than three times upper limit of normal) despite significantly elevated bilirubin, as was seen in our patient. SARM’s are a new class of medication that stimulate the anabolic effect on muscle without some of the adverse effects of anabolic steroids. Many in this class, including RAD140, are being evaluated in clinical trials for the treatment of diseases including muscular dystrophy and breast cancer but currently have no FDA approved indications. SARMs have been marketed to athletes as dietary supplements that will provide a competitive edge, but in 2017 the FDA issued a warning that these are drugs, not dietary supplements, and can have significant side effects, including liver injury and failure. Despite this warning and being on the banned list for competitive sports, these drugs are still marketed to athletes and available on-line. This case adds evidence that SARMs should be viewed similarly to anabolic steroids when forming a risk profile in a patient with suspected DILI. Identifying these substances as a possible etiology of DILI will help guide questioning when patients are less than forthcoming about their history.
Conclusions: This case highlights the need for hospitalists to recognize the pattern of anabolic steroid induced DILI and be aware that SARMs can have this affect. This case also emphasizes the importance of obtaining a complete drug/substance use history, including dietary supplements, over the counter medications and illicit substances.