P1875 - At What Cost: Drug-Induced Liver Injury Secondary to Selective Androgen Receptor Modulator

Henry Lam, DO¹, She-Yan Wong, MD^2
1Lehigh Valley Health Network, Easton, PA; ²Lehigh Valley Health Network, Allentown, PA

Introduction: Drug-induced liver injury (DILI) accounts for 10% of all cases of acute hepatitis. Over 1000 medications have been implicated in DILI. Symptoms include abdominal pain, jaundice, acholic stools, malaise, and even acute liver failure. Traditional androgenic anabolic steroids are well known to cause hepatotoxicity, but the implication with selective androgen receptor modulators (SARMs) is less well established. Here we highlight a case of DILI secondary to SARM.

Case Description/Methods: A 39-year-old male with no relevant history presents with fatigue, vomiting, jaundice, and dark urine for two weeks. He had been in his normal state of health prior to this without sick contacts, new partners, recent travel, or alcohol use. He recently stopped using SARMs for workout enhancement three weeks prior. Otherwise, he denied other new medications. Labs showed abnormal liver function including TB 12.4 mg/dL, AST 48 U/L, ALT 92 U/L, ALP 105 U/L with intact synthetic function, INR 0.9. Abdominal imaging was unremarkable except for mild hepatosplenomegaly. Serologies were negative including viral hepatitis panel, AMA, ASMA, ANA, IgG, and ceruloplasmin. Due to worsening symptoms and liver tests with TB > 35 mg/dL, patient underwent EUS guided liver biopsy. EUS showed no biliary obstruction. Liver pathology revealed cholestatic injury with normal hepatic architecture. No evidence of cirrhosis, steatosis, iron deposits, or PAS stains were noted. MRI abdomen showed patent bile ducts. Patient was diagnosed with cholestatic pattern DILI secondary to SARM. He was treated supportively, and liver function tests normalized about six months after initial presentation (Table 1).

Discussion: SARMs are tissue selective androgen derivatives that provide anabolic effects e.g., muscle and bone growth, without significant androgenic activities e.g., acne and prostate enlargement. Such selectivity has made SARM a potential treatment modality for muscular dystrophy, cancer-related cachexia, and osteoporosis, as well as performance enhancements amongst athletes. Unfortunately, these substances are not FDA regulated and easily obtained OTC making them dangerous agents. DILI is an increasingly recognized adverse effect highlighted by a rising number of case reports. Early recognition and drug cessation are key in the management of DILI.


Figure: Specimen obtained through EUS guided liver biopsy showing canalicular cholestasis.

	Initial Labs	1 week later	3 weeks later	3 months later	6 months later
TB (mg/dL)	12.4	28.8	> 35	1.2	0.8
AST (U/L)	48	64	93	80	25
ALT (U/L)	92	120	110	70	50
ALP (U/L)	105	125	218	60	70
Albumin (g/dL)	3.9	3.4	3.1	4.2	4
INR	0.9	1.1	1.3	--	--

Table: Table 1. Abnormal liver function tests with peak hepatotoxicity noted three weeks after initial presentation. Resolution and normalization of labs noted six months from initial presentation.


Disclosures:
Henry Lam indicated no relevant financial relationships.
She-Yan Wong indicated no relevant financial relationships.


Henry Lam, DO¹, She-Yan Wong, MD². P1875 - At What Cost: Drug-Induced Liver Injury Secondary to Selective Androgen Receptor Modulator, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.