Is it justifiable to withhold treatment for ASIH?

[Michael Scally MD]

Is it justifiable to withhold treatment for hepatitis C [ASIH] from illicit-drug users?

Ethical guidelines suggest that physicians offer treatment to persons who might benefit from it, take steps to improve the likelihood of a benefit, base treatment decisions on only those characteristics of patients that are clinically relevant, and respect the patient's informed decision to accept or decline treatment.

It may be difficult to make predictions about adherence in individual patients, but such assessments are likely to be more accurate, and more ethical, than the assumption that therapy is futile in all patients who use illicit drugs. Individualizing treatment decisions is standard medical practice in situations in which characteristics of the patient substantially influence the balance between risks and benefits.

Drug users, however, often need medical treatment. Moreover, they can be engaged in efforts to address their health care needs. Successful programs invariably adopt a respectful approach to drug users, understand the medical and behavioral sequelae of drug use, and refrain from making moralistic judgments.

The use of anabolic steroids, whether licit or illicit, has become highly politicized, thereby engendering a doctrinaire treatment regimen in response to medical conditions that arise out of such use: therapeutic treatment should be withheld, in view of “watchful waiting.”

Edlin BR, Seal KH, Lorvick J, et al. Is it justifiable to withhold treatment for hepatitis C from illicit-drug users? N Engl J Med 2001;345(3):211-5. MMS: Error / IS IT JUSTIFIABLE TO WITHHOLD TREATMENT FOR HEPATITIS C FROM ILLICIT-DRUG USERS?

 

[Burrr]

Is Hep C the condition that costs 10's of thousands to cure?

 

[Michael Scally MD]

Is Hep C the condition that costs 10's of thousands to cure?

There is a cure now available. In 2001, that was not the case.

 

[Prairie Boy]

What?really!?

 

[Michael Scally MD]

Hypogonadism Persistence After Long-Term Illicit Use Of Anabolic-Androgenic Steroids
https://www1.essm-congress.org/guest/AbstractView?ABSID=10325 (Abstract View)

Objective - Illicit use of anabolic–androgenic steroids has been a well-recognised problem in men for many years, and its use appears to be increasing. It is well established that this can lead to suppression of the hypothalamic-pituitary-testicular axis, with reduction in endogenous gonadotropin secretion, through negative feedback.

Cessation of illicit anabolic steroid use will then rapidly lead to consequent hypogonadism. It is sometimes less appreciated, by clinicians and patients alike, how long low testosterone levels can persist for.

Methods - A 38 year old man presented with erectile dysfunction and low energy. At the first consultation, he denied anabolic steroid use – though he later stated that he had been asked if he had “recently” used anabolic steroids, which he says he felt right to deny. Initial examination revealed no obvious abnormalities, apart from a mildly raised BMI of 28 (he was later noted to have small testicles).

Laboratory results revealed a low serum total testosterone, with two levels recorded under 7nmol/L. SHBG was a little raised at 65nmol/L. Free testosterone was reduced at 80pmol/L. LH was also reduced, 1.5iu/L.

The patient was referred and seen by the endocrinology team, and an MRI scan was arranged, which revealed no abnormalities.

He was seen in general practice for an unrelated matter, and he asked about his MRI scan. He stated he was extremely worried about his low testosterone results, and also expressed fears about fertility as he thought he may wish to start a family in the near future. Only on further direct questioning did he then admit to previous anabolic steroid misuse.

He reported having used them at high doses for 7-8 years, though had stopped 3 years previously. He had a new resolve to maintain a “natural and healthy” lifestyle, and says had felt embarrassed about reporting his previous use of steroids, but had thought any adverse effects would have dissipated over that 3 year period.

Results - As the patient was considering starting a family in the near future, he had a semen analysis which revealed a moderately reduced sperm count. With this in mind, he was started on clomiphene citrate, 50mg on alternate days. 3 months later, his total and free testosterone levels had increased a little, to 9.2nmol/L and 151pmol/L. He agreed he would defer a repeat semen analysis until definitely trying for a family.

Conclusion - It appears in this case that the most likely cause for hypogonadism was previous illicit anabolic steroid use, 3 years prior to presenting. There is some evidence that the duration of the hypogonadic effect is greater in older men, and those who have been using higher doses, and for a longer time. This case, in a man who meets most of these criteria, serves as a reminder that previous use must be fully explored.