Drug-induced Acute Pancreatitis in a Bodybuilder

Abstract and Introduction

Abstract

Background: Unregulated use of a variety of drugs and supplements by bodybuilders and athletes is common and can lead to severe adverse complications. Only a small proportion of acute pancreatitis cases are drug induced, and case reports are essential for identifying potential drug-related risks for pancreatitis. Here we present the first case report published of acute pancreatitis linked to recreational use of anabolic–androgenic steroids, subcutaneous growth hormone, and clenbuterol in a previously healthy male after excluding all other causes of pancreatitis.

Case Presentation: A 31-year-old Arab male bodybuilder presented with acute abdominal pain associated with nausea and sharp pain radiating to the back. The patient was not using tobacco or alcohol but was using multiple drugs related to bodybuilding, including anabolic–androgenic steroids, subcutaneous growth hormone, clenbuterol, and multiple vitamin supplements. Laboratory studies revealed a normal white blood cell count, elevated C-reactive protein, minimally elevated aspartate aminotransferase and total bilirubin with normal remaining liver tests, and elevated amylase and lipase. The patient had no hypertriglyceridemia or hypercalcemia, and had had no recent infections, abdominal procedures, trauma, or scorpion exposure. Imaging and laboratory investigations were negative for biliary disease and IgG4 disease. Abdominal computed tomography revealed hepatomegaly and diffuse thickening and edema of the body and tail of the pancreas with peripancreatic fat stranding. An abdominal ultrasound showed slight hepatomegaly with no evidence of cholelithiasis. Genetic testing for hereditary pancreatitis-related mutations was negative. A diagnosis of drug-induced acute pancreatitis was made, and he was treated with aggressive intravenous hydration and pain management. The patient has avoided further use of these drugs and supplements and had no further episodes of pancreatitis during 1 year of follow-up.

Conclusions: This case describes a patient with drug-induced acute pancreatitis after the intake of anabolic–androgenic steroids, subcutaneous growth hormone, and clenbuterol, where all other common causes of acute pancreatitis were excluded. Clinicians should be alert to the possibility of drug-induced acute pancreatitis occurring in bodybuilders and athletes using similar drug combinations.

Introduction

Supplements that enhance athletic performance and aesthetic appearance, such as growth hormone and anabolic–androgenic steroids (AAS), are commonplace among today's bodybuilder community.^[1,2] The lack of understanding and awareness of the detrimental adverse effects of such drugs can affect athletes' physical and mental health.^[2] The alarming increase in the unregulated use of these substances by bodybuilders can result in a variety of organ-specific pathologies, including pancreatitis, which is an inflammatory process that arises from pancreatic enzymes autodigesting the gland. The worldwide prevalence of acute pancreatitis is not known, but the annual estimates range between 5 and 80 per 100,000 people, with better-recorded data in the USA and Finland.^[3] The effects could range from mild to severe, with approximate mortality rates ranging from < 1% to > 30%.^[4,5] The most common presentation is severe epigastric pain, usually radiating to the back, and the diagnosis can be made through a combination of serum amylase and lipase, in addition to imaging studies such as abdominal ultrasound (US) and computed tomography (CT) scans. Gallstones (30–60%) and heavy alcohol use (15–30%) are the most reported causes of acute pancreatitis. However, endoscopic retrograde cholangiopancreatography (ERCP), trauma, hypertriglyceridemia, hyperparathyroidism, pancreatic tumors, surgery, infections, anatomic variants, and drug-induced acute pancreatitis (DIAP) are other less common etiologies.

Due to the inadequate literature on DIAP cases, the exact incidence and prevalence of this condition are not known. The diagnosis is one of exclusion, and immediate management of DIAP is to withdraw the offending agent and provide supportive care. If the offending drug is not identified early, it can result in irreversible damage to the gland, as well as increased length of hospitalization and repeated hospitalizations because of continuous intake of the substance.^[6,7] Hence, case reports are imperative to increasing awareness of uncommon causes of acute pancreatitis.

Table 1. Timeline table
Relevant past medical history and interventions
Past medical history insignificant for any pancreatic diseases or risk factors. He admitted to using anabolic–androgenic steroids, clenbuterol, multiple vitamin supplements, and growth hormone injection from an inexpensive supplier at double the recommended dose
Summaries from initial and follow-up visits	Diagnostic testing	Interventions
Based on clinical presentation and CT findings, the patient was diagnosed with acute pancreatitis with Bedside Index of Severity in Acute Pancreatitis (BISAP) score of 0 (< 1% risk of mortality), which is characterized by the absence of organ failure and local or systemic complications. During his hospital stay, the patient was managed with aggressive intravenous hydration and pain management, with significant improvement noticed within 3 days, after which he was discharged home	Laboratory studies: amylase, lipase	Discontinuation of offending drugs (anabolic–androgenic steroids, subcutaneous growth hormone, and clenbuterol); aggressive intravenous hydration and pain management
Patient had no further episodes of pancreatitis during 2 years of follow-up	Imaging: abdominal CT, abdominal ultrasound

Table 2. Cases of acute pancreatitis associated with drugs related to weightlifting or bodybuilding
Case	Patient	Findings	Drug(s) taken	Delay between introduction of the drug and pancreatitis	Rechallenge	Outcome
Safizadeh Shabestari et al. 2021 (our case)	31-year-old male	Elevated amylase and lipase, with CT abdomen showing pancreatitis	Fluoxymesterone, mesterolone, drostanolone propionate, stanozolol, tamoxifen, testosterone enanthate, testosterone propionate, clenbuterol, and growth hormone	1 month	Not performed	Clinical improvement with fluid hydration and pain management
Kumar et al. [16]	24-year-old male	Elevated amylase and lipase, with CT abdomen showing pancreatitis	Trenbolone acetate	Several months	Not performed	Clinical improvement with conservative treatment
Binet et al. [27]	28-year-old male	Isolated elevation of lipase, with CT abdomen showing pancreatitis	L-Arginine alpha-ketoglutarate and other vitamins and supplements	18 months	Not performed	Clinical improvement with conservative treatment
Liane et al. 2016 [5]	20-year-old male	Elevated amylase and lipase, LDH, and CK, with CT abdomen showing pancreatitis	Anabolic–androgenic steroid called "Guerilla Warfare"	1 month	Not performed	Clinical improvement with fluid hydration and pain management
Garg [17]	28-year-old male	Elevated amylase and lipase, with ultrasonography abdomen showing pancreatitis	Anabolic–androgenic steroid	Data unavailable	Not performed	Patient died
Rosenfeld et al. [28]	50-year-old male	Elevated lipase and triglycerides, with CT abdomen showing pancreatitis	Methandrostenolone	2 months	Not performed	Supportive therapy
Schäfer et al. [29]	26-year-old male	Hypercalcemia and elevated lactate dehydrogenase and pancreatic amylase, with CT abdomen showing pancreatitis	Oxymetholone, nandrolone decanoate, testosterone, epitestosterone, and erythropoietin	After second annual injection cycle	Not performed	Aggressive intravenous rehydration, transferred to intensive care unit because of anuria
Samaha et al. [2]	24-year-old male	Leukocytosis with left shift, hypercalcemia, and elevated amylase, lipase, and CPK	Testosterone	2 months	Not performed	Slow clinical improvement with fluid hydration and pain management
Rutten et al. [21]	40-year-old male	Elevated amylase and CRP with abdominal ultrasonography	Growth hormone	2 weeks	Not performed	Conservative treatment
Saka et al. [15]	16-year-old male	Elevated amylase and lipase with CT abdomen showing pancreatitis	L-Arginine and zinc	5 months	Not performed	Clinical improvement with ciprofloxacin, fluids, and bowel rest

Table 2. Cases of acute pancreatitis associated with drugs related to weightlifting or bodybuilding

Case

Patient

Findings

Drug(s) taken

Delay between introduction of the drug and pancreatitis

Rechallenge

Outcome

Safizadeh Shabestari et al. 2021 (our case)

31-year-old male

Elevated amylase and lipase, with CT abdomen showing pancreatitis

Fluoxymesterone, mesterolone, drostanolone propionate, stanozolol, tamoxifen, testosterone enanthate, testosterone propionate, clenbuterol, and growth hormone

1 month

Not performed

Clinical improvement with fluid hydration and pain management

Kumar et al. [16]

24-year-old male

Elevated amylase and lipase, with CT abdomen showing pancreatitis

Trenbolone acetate

Several months

Not performed

Clinical improvement with conservative treatment

Binet et al. [27]

28-year-old male

Isolated elevation of lipase, with CT abdomen showing pancreatitis

L-Arginine alpha-ketoglutarate and other vitamins and supplements

18 months

Not performed

Clinical improvement with conservative treatment

Liane et al. 2016 [5]

20-year-old male

Elevated amylase and lipase, LDH, and CK, with CT abdomen showing pancreatitis

Anabolic–androgenic steroid called "Guerilla Warfare"

1 month

Not performed

Clinical improvement with fluid hydration and pain management

Garg [17]

28-year-old male

Elevated amylase and lipase, with ultrasonography abdomen showing pancreatitis

Anabolic–androgenic steroid

Data unavailable

Not performed

Patient died

Rosenfeld et al. [28]

50-year-old male

Elevated lipase and triglycerides, with CT abdomen showing pancreatitis

Methandrostenolone

2 months

Not performed

Supportive therapy

Schäfer et al. [29]

26-year-old male

Hypercalcemia and elevated lactate dehydrogenase and pancreatic amylase, with CT abdomen showing pancreatitis

Oxymetholone, nandrolone decanoate, testosterone, epitestosterone, and erythropoietin

After second annual injection cycle

Not performed

Aggressive intravenous rehydration, transferred to intensive care unit because of anuria

Samaha et al. [2]

24-year-old male

Leukocytosis with left shift, hypercalcemia, and elevated amylase, lipase, and CPK

Testosterone

2 months

Not performed

Slow clinical improvement with fluid hydration and pain management

Rutten et al. [21]

40-year-old male

Elevated amylase and CRP with abdominal ultrasonography

Growth hormone

2 weeks

Not performed

Conservative treatment

Saka et al. [15]

16-year-old male

Elevated amylase and lipase with CT abdomen showing pancreatitis

L-Arginine and zinc

5 months

Not performed

Clinical improvement with ciprofloxacin, fluids, and bowel rest

Drug-induced Acute Pancreatitis in a Bodybuilder

A Case Report

Abstract and Introduction

Abstract

Introduction

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Drug-induced Acute Pancreatitis in a Bodybuilder

A Case Report

Abstract and Introduction

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