Nandrolone: Uses, Benefits & Side Effects

# Nandrolone: A Comprehensive Overview

Nandrolone is an anabolic‑steroid medication used in certain medical settings to treat conditions such as anemia, osteoporosis, and muscle wasting disorders. It’s also known for its use (or misuse) by athletes seeking performance enhancement, which has led to a complex regulatory and safety profile.

Below we cover the most important aspects of nandrolone—including how it works, where it is used medically, potential risks, legal status, and practical considerations for patients and healthcare providers.

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## 1. How Does Nandrolone Work?

### Mechanism of Action
- **Anabolic Effects**: Stimulates protein synthesis and nitrogen retention in muscle cells, leading to increased muscle mass and strength.
- **Osteogenic Effects**: Enhances bone mineral density by stimulating osteoblast activity (bone-forming cells).
- **Androgenic Effects**: Interacts with androgen receptors in various tissues; the balance of anabolic vs. androgenic activity depends on dose and route.

### Pharmacokinetics
- **Half‑life**: ~12–18 hours when given intramuscularly as an ester (e.g., nandrolone decanoate).
- **Metabolism**: Hepatic metabolism to inactive metabolites, excreted primarily via bile.
- **Bioavailability**: Good oral absorption but lower potency due to first‑pass hepatic metabolism.

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## 3. Clinical Indications and Evidence

| Indication | Level of Evidence | Summary |
|------------|-------------------|---------|
| **Anemia of chronic disease / ESRD** (especially where erythropoietin is ineffective or contraindicated) | Randomized controlled trials (RCTs); meta‑analyses | Effective in increasing hemoglobin and reducing transfusion needs; may improve quality of life. |
| **Iron deficiency anemia refractory to oral iron** | Case series, small RCTs | Can correct anemia and replenish iron stores when oral/IV iron fails or https://git.agusandelnorte.gov.ph/cassiec913211 is not tolerated. |
| **Myelodysplastic syndromes (MDS)** – low‑risk patients | Phase II trials; case reports | May increase red cell transfusion intervals; data limited. |
| **Chronic kidney disease (CKD) with anemia** | Observational studies | Limited evidence; may serve as adjunct to ESA therapy. |

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## 3. Potential Risks & Adverse Effects

| Risk / Adverse Effect | Frequency / Evidence | Management |
|-----------------------|----------------------|------------|
| **Iron overload** – especially in patients receiving repeated doses or those with chronic transfusions | High risk; reported ferritin >10,000 ng/mL and liver iron concentration 20 mg/g dry weight (case reports) | Monitor ferritin & transferrin saturation every 3–6 months. Consider phlebotomy if safe, defer dosing if ferritin >800 ng/mL or TSAT >45%. |
| **Oxidative tissue damage** – due to free radical generation | Experimental data; case reports of hepatic necrosis and nephrotoxicity | Avoid high doses; monitor liver enzymes (AST/ALT) & renal function (serum creatinine, eGFR). |
| **Hepatic dysfunction** – elevated ALT/AST, bilirubin | Case: 4 weeks after treatment, AST/ALT >10× ULN, serum bilirubin 5.2 mg/dL | Monitor LFTs every 1–2 weeks during therapy; discontinue if transaminases exceed 5× ULN or bilirubin rises >2 mg/dL. |
| **Nephrotoxicity** – rising creatinine, proteinuria | Case: Creatinine rise from baseline to 0.98 mg/dL after 4 weeks | Monitor serum creatinine and eGFR at baseline, then biweekly; consider dose adjustment or discontinuation if >25% increase in creatinine. |
| **Hemolytic anemia** – low hemoglobin, elevated LDH, indirect bilirubin | Case: Hb dropped from 13.8 g/dL to 11.4 g/dL, LDH increased | Check CBC and reticulocyte count weekly; if Hb <10 g/dL or transfusion needed, stop therapy. |
| **Hypersensitivity reactions** – rash, urticaria, angioedema | Common in first few days of infusion | Monitor skin and mucous membranes continuously; treat with antihistamines/ corticosteroids; discontinue if severe. |

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## 3. Suggested Monitoring Schedule

| Day / Time | Test / Observation | Rationale |
|------------|--------------------|-----------|
| **Day 0 (pre‑infusion)** | • CBC, CMP (renal & hepatic)
• Baseline bilirubin, LDH, haptoglobin
• Urinalysis
• Skin inspection for rash | Establish baseline; rule out pre‑existing hemolysis or organ dysfunction. |
| **Day 0 – Infusion** | • Vital signs (every 15–30 min)
• Monitor for anaphylaxis / urticaria | Rapid infusion can provoke allergic reactions. |
| **Day 1 (24 h post‑infusion)** | • CBC, CMP
• Bilirubin, LDH, haptoglobin
• Urinalysis | Detect early hemolytic response or renal impairment. |
| **Days 2–3** | Repeat labs as above | Continue monitoring for delayed hemolysis or rising creatinine. |
| **Day 4** | CBC & metabolic panel (if clinically indicated) | Confirm resolution of any abnormalities. |

> *Rationale:*
> • **CBC & CMP:** Early detection of anemia and electrolyte disturbances.
> • **LDH & haptoglobin:** Sensitive markers for intravascular hemolysis.
> • **Bilirubin & urinalysis:** Indicate extravascular hemolysis and hemoglobinuria.
> • **Creatinine:** Identifies acute kidney injury from hemoglobin overload.

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## 3. Management of Unexpected Severe Adverse Events

| Event | Immediate Actions | Follow‑up/Disposition |
|-------|-------------------|-----------------------|
| **Severe anaphylaxis (e.g., hypotension, bronchospasm)** | • Stop infusion immediately.
• Administer epinephrine IM 0.3 mg (1:1000) every 5–15 min if needed.
• Provide supplemental oxygen, IV fluids (30 mL/kg NS), and antihistamines.
• Monitor vitals continuously; consider ICU admission. | • Once stable, assess for future use of any biologic agent.
• Document reaction in patient chart. |
| **Severe urticaria or angioedema without systemic signs** | • Continue infusion if tolerated; monitor closely.
• Administer antihistamines (diphenhydramine 25 mg IV or orally).
• Consider premedication for subsequent infusions: steroids + antihistamine. | • Reevaluate necessity of therapy; if essential, proceed with caution. |
| **Anaphylactic shock** | Immediate emergency response: epinephrine IM/IV, airway management, oxygen, fluids.
Stop infusion immediately. | Initiate advanced life support protocols; document event. |

### 3.5 Monitoring During Infusion

- **Vital Signs:** Monitor baseline BP, HR, RR, SpO₂ before infusion and every 15–30 min during first hour; then hourly if stable.
- **Symptoms:** Observe for pruritus, rash, urticaria, throat tightness, dizziness, headache.
- **Laboratory Tests (Optional):** Baseline CBC, CMP, CRP. Repeat after 24–48 h to assess inflammatory markers.

### 3.6 Post‑Infusion Care

- **Observation Period:** 1–2 h post‑infusion for delayed reactions.
- **Follow‑up:** Check in with patient within 24 h; monitor for any new symptoms or laboratory abnormalities.
- **Documentation:** Record all observations, interventions, and patient responses.

### 3.7 Discharge Criteria

- No signs of hypersensitivity (rash, pruritus, swelling).
- Vital signs stable.
- Patient educated on symptom monitoring and when to seek help.

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## 4. Risk Mitigation

| Potential Complication | Preventive Measure | Management Plan |
|------------------------|--------------------|-----------------|
| **Hypersensitivity reaction** | Pre‑medication with antihistamine; baseline skin test for high‑risk patients. | Immediate epinephrine, antihistamines, steroids; monitor airway. |
| **Severe hypotension** | Use slow infusion; monitor BP continuously. | IV fluids and vasopressors if needed. |
| **Injection site pain/hematoma** | Proper technique, use of small gauge needle. | Apply ice, analgesics. |
| **Infection** | Sterile field, aseptic technique. | Antibiotics if infection suspected. |

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## 5. Patient Education & Documentation

1. **Explain the purpose** of the treatment and expected benefits.
2. **Inform about possible side‑effects**, such as temporary pain or swelling at injection site.
3. **Advise on after‑care**: avoid strenuous activity for a few hours, keep area clean.
4. **Provide written instructions** if possible.
5. **Record in chart**:
* Date/time of procedure
* Medication name, dose, route, and lot number
* Site of injection
* Any immediate reactions
* Patient’s verbal consent

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### Final Note

Always verify that the medication is intended for the specific indication and that it has been properly compounded. If you have any doubts about dosage or appropriateness for a patient, consult with the prescribing provider or pharmacist before proceeding.