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Clostebol acetate

1. NAME
   1.1 Substance
   1.2 Group
   1.3 Synonyms
   1.4 Identification numbers
      1.4.1 CAS number
      1.4.2 Other numbers
   1.5 Main brand names, main trade names
   1.6 Main manufacturers, main importers
2. SUMMARY
   2.1 Main risks and target organs
   2.2 Summary of clinical effects
   2.3 Diagnosis
   2.4 First aid measures and management principles
3. PHYSICO-CHEMICAL PROPERTIES
   3.1 Origin of the substance
   3.2 Chemical structure
   3.3 Physical properties
      3.3.1 Colour
      3.3.2 State/form
      3.3.3 Description
   3.4 Other characteristics
      3.4.1 Shelf-life of the substance
      3.4.2 Storage conditions
4. USES
   4.1 Indications
      4.1.1 Indications
      4.1.2 Description
   4.2 Therapeutic dosage
      4.2.1 Adults
      4.2.2 Children
   4.3 Contraindications
5. ROUTES OF EXPOSURE
   5.1 Oral
   5.2 Inhalation
   5.3 Dermal
   5.4 Eye
   5.5 Parenteral
   5.6 Other
6. KINETICS
   6.1 Absorption by route of exposure
   6.2 Distribution by route of exposure
   6.3 Biological half-life by route of exposure
   6.4 Metabolism
   6.5 Elimination by route of exposure
7. PHARMACOLOGY AND TOXICOLOGY
   7.1 Mode of action
      7.1.1 Toxicodynamics
      7.1.2 Pharmacodynamics
   7.2 Toxicity
      7.2.1 Human data
         7.2.1.1 Adults
         7.2.1.2 Children
      7.2.2 Relevant animal data
      7.2.3 Relevant in vitro data
   7.3 Carcinogenicity
   7.4 Teratogenicity
   7.5 Mutagenicity
   7.6 Interactions
   7.7 Main adverse effects
8. TOXICOLOGICAL ANALYSES AND BIOMEDICAL INVESTIGATIONS
   8.1 Material sampling plan
      8.1.1 Sampling and specimen collection
         8.1.1.1 Toxicological analyses
         8.1.1.2 Biomedical analyses
         8.1.1.3 Arterial blood gas analysis
         8.1.1.4 Haematological analyses
         8.1.1.5 Other (unspecified) analyses
      8.1.2 Storage of laboratory samples and specimens
         8.1.2.1 Toxicological analyses
         8.1.2.2 Biomedical analyses
         8.1.2.3 Arterial blood gas analysis
         8.1.2.4 Haematological analyses
         8.1.2.5 Other (unspecified) analyses
      8.1.3 Transport of laboratory samples and specimens
         8.1.3.1 Toxicological analyses
         8.1.3.2 Biomedical analyses
         8.1.3.3 Arterial blood gas analysis
         8.1.3.4 Haematological analyses
         8.1.3.5 Other (unspecified) analyses
   8.2 Toxicological Analyses and Their Interpretation
      8.2.1 Tests on toxic ingredient(s) of material
         8.2.1.1 Simple Qualitative Test(s)
         8.2.1.2 Advanced Qualitative Confirmation Test(s)
         8.2.1.3 Simple Quantitative Method(s)
         8.2.1.4 Advanced Quantitative Method(s)
      8.2.2 Tests for biological specimens
         8.2.2.1 Simple Qualitative Test(s)
         8.2.2.2 Advanced Qualitative Confirmation Test(s)
         8.2.2.3 Simple Quantitative Method(s)
         8.2.2.4 Advanced Quantitative Method(s)
         8.2.2.5 Other Dedicated Method(s)
      8.2.3 Interpretation of toxicological analyses
   8.3 Biomedical investigations and their interpretation
      8.3.1 Biochemical analysis
         8.3.1.1 Blood, plasma or serum
         8.3.1.2 Urine
         8.3.1.3 Other fluids
      8.3.2 Arterial blood gas analyses
      8.3.3 Haematological analyses
      8.3.4 Interpretation of biomedical investigations
   8.4 Other biomedical (diagnostic) investigations and their interpretation
   8.5 Overall Interpretation of all toxicological analyses and toxicological investigations
   8.6 References
9. CLINICAL EFFECTS
   9.1 Acute poisoning
      9.1.1 Ingestion
      9.1.2 Inhalation
      9.1.3 Skin exposure
      9.1.4 Eye contact
      9.1.5 Parenteral exposure
      9.1.6 Other
   9.2 Chronic poisoning
      9.2.1 Ingestion
      9.2.2 Inhalation
      9.2.3 Skin exposure
      9.2.4 Eye contact
      9.2.5 Parenteral exposure
      9.2.6 Other
   9.3 Course, prognosis, cause of death
   9.4 Systematic description of clinical effects
      9.4.1 Cardiovascular
      9.4.2 Respiratory
      9.4.3 Neurological
         9.4.3.1 Central nervous system
         9.4.3.2 Peripheral nervous system
         9.4.3.3 Autonomic nervous system
         9.4.3.4 Skeletal and smooth muscle
      9.4.4 Gastrointestinal
      9.4.5 Hepatic
      9.4.6 Urinary
         9.4.6.1 Renal
         9.4.6.2 Other
      9.4.7 Endocrine and reproductive systems
      9.4.8 Dermatological
      9.4.9 Eye, ear, nose, throat: local effects
      9.4.10 Haematological
      9.4.11 Immunological
      9.4.12 Metabolic
         9.4.12.1 Acid-base disturbances
         9.4.12.2 Fluid and electrolyte disturbances
         9.4.12.3 Others
      9.4.13 Allergic reactions
      9.4.14 Other clinical effects
      9.4.15 Special risks
   9.5 Other
   9.6 Summary
10. MANAGEMENT
   10.1 General principles
   10.2 Life supportive procedures and symptomatic/specific treatment
   10.3 Decontamination
   10.4 Enhanced elimination
   10.5 Antidote treatment
      10.5.1 Adults
      10.5.2 Children
   10.6 Management discussion
11. ILLUSTRATIVE CASES
   11.1 Case reports from literature
12. Additional information
   12.1 Specific preventive measures
   12.2 Other
13. REFERENCES
14. AUTHOR(S), REVIEWER(S), DATE(S) (INCLUDING UPDATES), COMPLETE ADDRESS(ES)
    Clostebol acetate

    International Programme on Chemical Safety
    Poisons Information Monograph  900
    Pharmaceutical

    This monograph does not contain all of the sections completed. This
    mongraph is harmonised with the Group monograph on Anabolic Steroids
    (PIM G007).

    1.  NAME

        1.1  Substance

             Clostebol acetate

        1.2  Group

             ATC Classification:
             A14 (Anabolic Agents for Systemic Use)
             A14A (Anabolic steroids)

        1.3  Synonyms

             4-Chlorotestosterone Acetate; Chlortestosterone Acetate

        1.4  Identification numbers

             1.4.1  CAS number

                    855-19-6 (clostebol acetate)

             1.4.2  Other numbers

                    CAS: 1093-58-9 (clostebol)

        1.5  Main brand names, main trade names

             Alfa-Trofodermin; Clostene (FM); Megagrisevit mono;
             Steranabol (FM)

        1.6  Main manufacturers, main importers

    2.  SUMMARY

        2.1  Main risks and target organs

             There is no serious risk from acute poisoning, but
             chronic use can cause harm. The main risks are those of
             excessive androgens: menstrual irregularities and
             virilization in women and impotence, premature cardiovascular
             disease and prostatic hypertrophy in men. Both men and women
             can suffer liver damage with oral anabolic steroids

             containing a substituted 17-alpha-carbon. Psychiatric changes
             can occur during use or after cessation of these
             agents.

        2.2  Summary of clinical effects

             Acute overdosage can produce nausea and gastrointestinal
             upset. Chronic usage is thought to cause an increase in
             muscle bulk, and can cause an exageration of male
             characteristics and effects related to male hormones.
             Anabolic steroids can influence sexual function. They can
             also cause cardiovascular and hepatic damage. Acne and male-
             pattern baldness occur in both sexes; irregular menses,
             atrophy of the breasts, and clitoromegaly in women; and
             testicular atrophy and prostatic hypertrophy in men. 

        2.3  Diagnosis

             The diagnosis depends on a history of use of oral or
             injected anabolic steroids, together with signs of increased
             muscle bulk, commonly seen in "body-builders". Biochemical
             tests of liver function are often abnormal in patients who
             take excessive doses of oral anabolic steroids.
    
             Laboratory analyses of urinary anabolic steroids and their
             metabolites can be helpful in detecting covert use of these
             drugs.

        2.4  First aid measures and management principles

             Supportive care is the only treatment necessary or
             appropriate for acute intoxication. Chronic (ab)users can be
             very reluctant to cease abuse, and may require professional
             help as with other drug misuse.

    3.  PHYSICO-CHEMICAL PROPERTIES

        3.1  Origin of the substance

             Naturally-occuring anabolic steroids are synthesised in
             the testis, ovary and adrenal gland from cholesterol via
             pregnenolone. Synthetic anabolic steroids are based on the
             principal male hormone testosterone, modified in one of three
             ways:
    
             alkylation of the 17-carbon
             esterification of the 17-OH group
             modification of the steroid nucleus
    
             (Murad & Haynes, 1985).

        3.2  Chemical structure

             Chemical name:
    
             Clostebol acetate: 4-Chloro-3-oxoandrost-4-en-17beta-yl
             acetate
    
             Alterenative:  4-Chloro-17beta-hydroxyandrost-4-en-3-one
             acetate
    
             Clostebol: 4-chloro-17-hydroxy-(17b)-Androst-4-en-3-one,
    
             Molecular Formula:
             Clostebol acetate: C21H29ClO3
    
             Molecular Weight:
             Clostebol acetate: 364.9

        3.3  Physical properties

             3.3.1  Colour


             3.3.2  State/form

             3.3.3  Description

        3.4  Other characteristics

             3.4.1  Shelf-life of the substance

             3.4.2  Storage conditions

                    Protect from light.
    
                    Vials for parenteral administration should be stored
                    at room temperature (15 to 30C). Visual inspection
                    for particulate and/or discoloration is
                    advisable.

    4.  USES

        4.1  Indications

             4.1.1  Indications

                    Anabolic agent; systemic
                    Anabolic steroid
                             Androstan derivative; anabolic steroid
                             Estren derivative; anabolic steroid
                             Other anabolic agent
                    Anabolic agent for systemic use; veterinary
                             Anabolic steroid; veterinary
                             Estren derivative; veterinary

             4.1.2  Description

                    The only legitimate therapeutic indications for
                    anabolic steroids are:
    
                    (a) replacement of male sex steroids in men who have
                    androgen deficiency, for example as a result of loss
                    of both testes
    
                    (b) the treatment of certain rare forms of aplastic
                    anaemia which are or may be responsive to anabolic
                    androgens.
    
                    (ABPI Data Sheet Compendium, 1993)
    
                    (c) the drugs have been used in certain countries to
                    counteract catabolic states, for example after major
                    trauma.
    
                    Clostebol acetate has been applied topically in
                    dermatological and ophthalmological preparations.
                    Clostebol has also been used.

        4.2  Therapeutic dosage

             4.2.1  Adults

             4.2.2  Children

                    Not applicable

        4.3  Contraindications

             Known or suspected cancer of the prostate or (in men)
             breast.
             Pregnancy or breast-feeding.
             Known cardiovascular disease is a relative contraindication.

    5.  ROUTES OF EXPOSURE

        5.1  Oral

             Anabolic steroids can be absorbed from the
             gastrointestinal tract, but many compounds undergo such
             extensive first-pass metabolism in the liver that they are
             inactive. Those compounds in which substitution of the 17-
             carbon protects the compound from the rapid hepatic
             metabolism are active orally (Murad and Haynes, 1985).
             There are preparations of testosterone that can be taken
             sublingually.

        5.2  Inhalation

             Not relevant

        5.3  Dermal

             No data available

        5.4  Eye

             Not relevant

        5.5  Parenteral

             Intramuscular or deep subcutaneous injection is the
             principal route of administration of all the anabolic
             steroids except the 17-alpha-substituted steroids which are
             active orally.

        5.6  Other

             Not relevant

    6.  KINETICS

        6.1  Absorption by route of exposure

             The absorption after oral dosing is rapid for
             testosterone and probably for other anabolic steroids, but
             there is extensive first-pass hepatic metabolism for all
             anabolic steroids except those that are substituted at the
             17-alpha position.
    
             The rate of absorption from subcutaneous or intramuscular
             depots depends on the product and its formulation. Absorption
             is slow for the lipid-soluble esters such as the cypionate or
             enanthate, and for oily suspensions.

        6.2  Distribution by route of exposure

             The anabolic steroids are highly protein bound, and is
             carried in plasma by a specific protein called sex-hormone
             binding globulin.

        6.3  Biological half-life by route of exposure

             The metabolism of absorbed drug is rapid, and the
             elimination half-life from plasma is very short. The duration
             of the biological effects is therefore determined almost
             entirely by the rate of absorption from subcutaneous or
             intramuscular depots, and on the de-esterification which
             precedes it (Wilson, 1992).

        6.4  Metabolism

             Free (de-esterified) anabolic androgens are metabolized
             by hepatic mixed function oxidases (Wilson, 1992).

        6.5  Elimination by route of exposure

             After administration of radiolabelled testosterone,
             about 90% of the radioactivity appears in the urine, and 6%
             in the faeces; there is some enterohepatic recirculation
             (Wilson, 1992).

    7.  PHARMACOLOGY AND TOXICOLOGY

        7.1  Mode of action

             7.1.1  Toxicodynamics

                    The toxic effects are an exaggeration of the
                    normal pharmacological effects.

             7.1.2  Pharmacodynamics

                    Anabolic steroids bind to specific receptors
                    present especially in reproductive tissue, muscle and
                    fat (Mooradian & Morley, 1987). The anabolic steroids
                    reduce nitrogen excretion from tissue breakdown in
                    androgen deficient men. They are also responsible for
                    normal male sexual differentiation. The ratio of
                    anabolic ("body-building") effects to androgenic
                    (virilizing) effects may differ among the members of
                    the class, but in practice all agents possess both
                    properties to some degree. There is no clear evidence
                    that anabolic steroids enhance overall athletic
                    performance (Elashoff et al, 1991).

        7.2  Toxicity

             7.2.1  Human data

                    7.2.1.1  Adults

                             No data available.

                    7.2.1.2  Children

                             No data available.

             7.2.2  Relevant animal data

                    No data available.

             7.2.3  Relevant in vitro data

                    No data

        7.3  Carcinogenicity

             Anabolic steroids may be carcinogenic. They can
             stimulate growth of sex-hormone dependent tissue, primarily
             the prostate gland in men. Precocious prostatic cancer has
             been described after long-term anabolic steroid abuse(Roberts
             & Essenhigh, 1986). Cases where hepatic cancers have been
             associated with anabolic steroid abuse have been reported
             (Overly et al, 1984).

        7.4  Teratogenicity

             Androgen ingestion by a pregnant mother can cause
             virilization of a female fetus (Dewhurst & Gordon,
             1984).

        7.5  Mutagenicity

             No data available.

        7.6  Interactions

             No data available.

        7.7  Main adverse effects

             The adverse effects of anabolic steroids include weight
             gain, fluid retention, and abnormal liver function as
             measured by biochemical tests. Administration to children can
             cause premature closure of the epiphyses. Men can develop
             impotence and azoospermia. Women are at risk of
             virilization.

    8.  TOXICOLOGICAL ANALYSES AND BIOMEDICAL INVESTIGATIONS

        8.1  Material sampling plan
             8.1.1  Sampling and specimen collection
                    8.1.1.1  Toxicological analyses
                    8.1.1.2  Biomedical analyses
                    8.1.1.3  Arterial blood gas analysis
                    8.1.1.4  Haematological analyses
                    8.1.1.5  Other (unspecified) analyses
             8.1.2  Storage of laboratory samples and specimens
                    8.1.2.1  Toxicological analyses
                    8.1.2.2  Biomedical analyses
                    8.1.2.3  Arterial blood gas analysis
                    8.1.2.4  Haematological analyses
                    8.1.2.5  Other (unspecified) analyses
             8.1.3  Transport of laboratory samples and specimens
                    8.1.3.1  Toxicological analyses
                    8.1.3.2  Biomedical analyses
                    8.1.3.3  Arterial blood gas analysis

                    8.1.3.4  Haematological analyses
                    8.1.3.5  Other (unspecified) analyses
        8.2  Toxicological Analyses and Their Interpretation
             8.2.1  Tests on toxic ingredient(s) of material
                    8.2.1.1  Simple Qualitative Test(s)
                    8.2.1.2  Advanced Qualitative Confirmation Test(s)
                    8.2.1.3  Simple Quantitative Method(s)
                    8.2.1.4  Advanced Quantitative Method(s)
             8.2.2  Tests for biological specimens
                    8.2.2.1  Simple Qualitative Test(s)
                    8.2.2.2  Advanced Qualitative Confirmation Test(s)
                    8.2.2.3  Simple Quantitative Method(s)
                    8.2.2.4  Advanced Quantitative Method(s)
                    8.2.2.5  Other Dedicated Method(s)
             8.2.3  Interpretation of toxicological analyses
        8.3  Biomedical investigations and their interpretation
             8.3.1  Biochemical analysis
                    8.3.1.1  Blood, plasma or serum
                    8.3.1.2  Urine
                    8.3.1.3  Other fluids
             8.3.2  Arterial blood gas analyses
             8.3.3  Haematological analyses
             8.3.4  Interpretation of biomedical investigations

        8.4  Other biomedical (diagnostic) investigations and their
             interpretation

        8.5  Overall Interpretation of all toxicological analyses and
             toxicological investigations

             Biomedical analysis
             The following tests can be relevant in the investigation of
             chronic anabolic steroid abuse:
             a) full blood count
             b) electrolytes and renal function tests
             c) hepatic function tests
             d) testosterone
             e) Lutenizing hormone
             f) prostatic acid phosphatase or prostate related antigen
             g) blood glucose concentration
             h) cholesterol concentration
    
             Toxicological analysis
             -urinary analysis for anabolic steroids and their
             metabolites
    
             Other investigations
             -electrocardiogram

        8.6  References

    9.  CLINICAL EFFECTS

        9.1  Acute poisoning

             9.1.1  Ingestion

                    Nausea and vomiting can occur.

             9.1.2  Inhalation

                    Not relevant

             9.1.3  Skin exposure

                    Not relevant

             9.1.4  Eye contact

                    Not relevant

             9.1.5  Parenteral exposure

                    Patients are expected to recover rapidly after
                    acute overdosage, but there are few  data. "Body-
                    builders" use doses many times the standard
                    therapeutic doses for these compounds but do not
                    suffer acute toxic effects.

             9.1.6  Other

                    Not relevant

        9.2  Chronic poisoning

             9.2.1  Ingestion

                    Hepatic damage, manifest as derangement of
                    biochemical tests of liver function and sometimes
                    severe enough to cause jaundice; virilization in
                    women; prostatic hypertrophy, impotence and
                    azoospermia in men; acne, abnormal lipids, premature
                    cardiovascular disease (including stroke and
                    myocardial infarction), abnormal glucose tolerance,
                    and muscular hypertrophy in both sexes; psychiatric
                    disturbances can occur during or after prolonged
                    treatment (Ferner & Rawlins, 1988; Kennedy, 1992; Ross
                    & Deutch, 1990; Ryan, 1981; Wagner, 1989).

             9.2.2  Inhalation

                    Not relevant

             9.2.3  Skin exposure

                    Not relevant

             9.2.4  Eye contact

                    Not relevant

             9.2.5  Parenteral exposure

                    Virilization in women; prostatic hypertrophy,
                    impotence and azoospermia in men; acne, abnormal
                    lipids, premature cardiovascular disease (including
                    stroke and myocardial infarction), abnormal glucose
                    tolerance, and muscular hypertrophy in both sexes.
                    Psychiatric disturbances can occur during or after
                    prolonged treatment. Hepatic damage is not expected
                    from parenteral preparations.

             9.2.6  Other

                    Not relevant

        9.3  Course, prognosis, cause of death

             Patients with symptoms of acute poisoning are expected
             to recover rapidly. Patients who persistently abuse high
             doses of anabolic steroids are at risk of death from
             premature heart disease or cancer, especially prostatic
             cancer. Non-fatal but long-lasting effects include voice
             changes in women and fusion of the epiphyses in children.
             Other effects are reversible over weeks or months.

        9.4  Systematic description of clinical effects

             9.4.1  Cardiovascular

                    Chronic ingestion of high doses of anabolic
                    steroids can cause elevations in blood pressure, left
                    ventricular hypertrophy and premature coronary artery
                    disease (McKillop et al., 1986; Bowman, 1990; McNutt
                    et al., 1988).

             9.4.2  Respiratory

                    Not reported

             9.4.3  Neurological

                    9.4.3.1  Central nervous system

                             Stroke has been described in a young
                             anabolic steroid abuser (Frankle et al., 
                             1988).
    
                             Pope & Katz (1988) described mania and
                             psychotic symptoms of hallucination and
                             delusion in anabolic steroid abusers. They
                             also described depression after withdrawal
                             from anabolic steroids.  There is also
                             considerable debate about the effects of
                             anabolic steroids on aggressive behaviour
                             (Schulte et al., 1993) and on criminal
                             behaviour (Dalby, 1992). Mood swings were
                             significantly more common in normal
                             volunteers during the active phase of a trial
                             comparing methyltestosterone with placebo (Su
                             et al., 1993).

                    9.4.3.2  Peripheral nervous system

                             No data available

                    9.4.3.3  Autonomic nervous system

                             No data available

                    9.4.3.4  Skeletal and smooth muscle

                             No data available

             9.4.4  Gastrointestinal

                    Acute ingestion of large doses can cause nausea
                    and gastrointestinal upset.

             9.4.5  Hepatic

                    Orally active (17-alpha substituted) anabolic
                    steroids can cause abnormalities of hepatic function,
                    manifest as abnormally elevated hepatic enzyme
                    activity in biochemical tests of liver function, and
                    sometimes as overt jaundice.
    
                    The histological abnormality of peliosis hepatis has
                    been associated with anabolic steroid use (Soe et al.,
                    1992).
    

                    Angiosarcoma (Falk et al, 1979) and a case of
                    hepatocellular carcinoma in an anabolic steroid user
                    has been reported (Overly et al., 1984).

             9.4.6  Urinary

                    9.4.6.1  Renal

                             Not reported

                    9.4.6.2  Other

                             Men who take large doses of anabolic
                             steroids can develop prostatic hypertrophy.
                             Prostatic carcinoma has been described in
                             young men who have abused anabolic steroids
                             (Roberts & Essenhigh, 1986).

             9.4.7  Endocrine and reproductive systems

                    Small doses of anabolic steroids are said to
                    increase libido, but larger doses lead to azoospermia
                    and impotence. Testicular atrophy is a common clinical
                    feature of long-term abuse of anabolic steroids, and
                    gynaecomastia can occur (Martikainen et al., 1986;
                    Schurmeyer et al., 1984;  Spano & Ryan, 1984).
    
                    Women develop signs of virilism, with increased facial
                    hair, male pattern baldness, acne, deepening of the
                    voice, irregular menses and clitoral enlargement
                    (Malarkey et al., 1991; Strauss et al., 1984).

             9.4.8  Dermatological

                    Acne occurs in both male and female anabolic
                    steroids abusers.  Women can develop signs of
                    virilism, with increased facial hair and male pattern
                    baldness.

             9.4.9  Eye, ear, nose, throat: local effects

                    Changes in the larynx in women caused by
                    anabolic steroids can result in a hoarse, deep voice.
                    The changes are irreversible.

             9.4.10 Haematological

                    Anabolic androgens stimulate
                    erythropoesis.

             9.4.11 Immunological

                    No data available

             9.4.12 Metabolic

                    9.4.12.1 Acid-base disturbances

                             No data available.

                    9.4.12.2 Fluid and electrolyte disturbances

                             Sodium and water retention can
                             occur, and result in oedema; hypercalcaemia
                             is also reported (Reynolds, 1992).

                    9.4.12.3 Others

                             Insulin resistance with a fall in
                             glucose tolerance (Cohen & Hickman, 1987),
                             and hypercholesterolaemia with a fall in high
                             density lipoprotein cholesterol, have been
                             reported (Cohen et al., 1988; Glazer, 1991;
                             Webb et al., 1984).

             9.4.13 Allergic reactions

                    No data available

             9.4.14 Other clinical effects

                    No data available

             9.4.15 Special risks

                    Risk of abuse

        9.5  Other

             No data available

        9.6  Summary

    10. MANAGEMENT

        10.1 General principles

             The management of acute overdosage  consists of
             supportive treatment, with fluid replacement if vomiting is
             severe.  Chronic abuse should be discouraged, and
             psychological support may be needed as in the treatment of
             other drug abuse. The possibility of clinically important
             depression after cessation of usage should be borne in
             mind.

        10.2 Life supportive procedures and symptomatic/specific treatment

             Not relevant

        10.3 Decontamination

             Not usually required.

        10.4 Enhanced elimination

             Not indicated

        10.5 Antidote treatment

             10.5.1 Adults

                    None available

             10.5.2 Children

                    None available

        10.6 Management discussion

             Not relevant

    11. ILLUSTRATIVE CASES

        11.1 Case reports from literature

             A 38-year old man presented with acute urinary
             retention, and was found to have carcinoma of the prostate.
             He had taken anabolic steroids for many years, and worked as
             a "strong-man" (Roberts and Essenhigh, 1986).
    
             A 22-year old male world-class weight lifter developed severe
             chest pain awaking him from sleep, and was shown to have
             myocardial infarction. For six weeks before, he had been
             taking high doses of oral and injected anabolic steroids.
             Total serum cholesterol was 596 mg/dL (HDL 14 mg/dL, LDL 513
             mg/dL) (McNutt et al., 1988). Values of total cholesterol
             concentration above 200 mg/dL are considered undesirable.
    
             A 22-year old body builder took two eight-week courses of
             anabolic steroids. He became severely depressed after the
             second course, and when the depression gradually receded, he
             had prominent paranoid and religious delusions (Pope and
             Katz, 1987).
    
             A 19-year old American college footballer took intramuscular
             testosterone and oral methandrostenolone over 4 months. He
             became increasingly aggressive with his wife and child. After

             he severely injured the child, he ceased using anabolic
             steroids, and his violence and aggression resolved within 2
             months (Schulte et al, 1993).

    12. Additional information

        12.1 Specific preventive measures

             Anabolic steroid abuse amongst athletes, weight
             lifters, body builders and others is now apparently common at
             all levels of these sports. Not all abusers are competitive
             sportsmen.
             There is therefore scope for a public health campaign, for
             example, based on gymnasia, to emphasize the dangers of
             anabolic steroid abuse and to support those who wish to stop
             using the drugs.

        12.2 Other

             No data available.

    13. REFERENCES

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    14. AUTHOR(S), REVIEWER(S), DATE(S) (INCLUDING UPDATES), COMPLETE
        ADDRESS(ES)

        Author:       Dr R. E. Ferner,
                      West Midlands Centre for Adverse Drug Reaction
                      Reporting,
                      City Hospital Dudley Road,
                      Birmingham B18  7QH
                      England.
                      Tel: +44-121-5074587
                      Fax: +44-121-5236125
                      Email: fernerre@bham.ac.uk
    

        Date:         1994
    
        Peer review:  INTOX Meeting, Sao Paulo, Brazil, September 1994
                      (Drs P.Kulling, R.McKuowen, A.Borges, R.Higa,
                      R.Garnier, Hartigan-Go, E.Wickstrom)
    
        Editor:       Dr M.Ruse, March 1998
    


    See Also:
       Toxicological Abbreviations