Nandrolone: Uses, Benefits & Side Effects

**Anabolic Androgenic Steroid (AAS) Overview for Healthcare Professionals**
*Prepared by the Medical Advisory Board – July 2024*

---

## 1. Introduction

Anabolic androgenic steroids (AAS) are synthetic derivatives of testosterone that promote protein synthesis, muscle hypertrophy, and bone density while exerting androgenic effects on secondary sexual characteristics. They have a long history in clinical medicine for treating:

- **Hypogonadism** (primary or secondary)
- **Chronic anemias & cachexia** (e.g., cancer‑related wasting)
- **Delayed puberty** (in boys with hypogonadotropic hypogonadism)
- **Osteoporosis** and fractures in men
- **Certain endocrine disorders** (e.g., androgen deficiency syndromes)

While the therapeutic benefits are significant, https://zenwriting.net/coffeeneed3/top-14-steroid-cycles-for-novice-intermediate-and-advanced-users AAS therapy is associated with a spectrum of adverse effects—ranging from mild to life‑threatening—that must be carefully monitored. The following sections provide an evidence‑based review of these risks, drawing on systematic reviews, meta‑analyses, and large observational studies.

---

## 1. Cardiovascular Toxicity

| Outcome | Evidence Summary |
|---------|-------------------|
| **Hypertension** | Multiple cohort studies (e.g., 12,000 men on testosterone therapy) report a 15–20 % increase in systolic BP after 6 months; RCTs show mean rises of 5–10 mmHg. |
| **Atherosclerosis & Plaque Formation** | Meta‑analysis of 25 observational studies (n=18,000) indicates higher carotid intima‑media thickness (IMT) in users vs. non‑users (ΔIMT ≈ 0.04 mm). |
| **Coronary Artery Disease (CAD)** | Prospective studies show relative risk (RR) of CAD events ~1.3–1.5 for men >55 y on testosterone therapy; not significant in women or younger cohorts. |
| **Stroke** | Limited evidence: one cohort (n=5,000) reported RR 1.6 (95% CI 0.9‑2.8); meta‑analysis (4 studies) found no statistically significant increase (RR ≈ 1.1). |

*Interpretation:* The data suggest a modest but clinically relevant elevation in CAD risk among older men on testosterone therapy, with insufficient evidence to confirm an increased stroke risk.

---

## 3. Clinical Guidance

| **Population** | **Key Recommendations** | **Monitoring Plan** |
|----------------|--------------------------|---------------------|
| **Healthy young adults (≤30 yr)** | • Use only as directed for medical conditions (e.g., hypogonadism).
• Avoid off‑label or recreational use. | • Baseline: CBC, CMP, lipid panel, fasting glucose, testosterone level.
• Follow‑up every 3–6 mo: repeat labs + clinical review. |
| **Middle‑aged adults (31–50 yr)** | • Evaluate for underlying endocrine disorders before prescribing.
• Counsel on potential cardiovascular risks and lifestyle factors. | • Same as above, plus baseline ECG if cardiac risk factors present.
• Monitor lipid profile more frequently if dyslipidemia. |
| **Older adults (>50 yr)** | • Consider frailty; weigh benefits vs risks (e.g., osteoporosis, prostate issues).
• Prefer non‑hormonal interventions for mood/sedation when possible. | • More intensive monitoring: labs every 3–6 months.
• Regular bone density scans if long‑term use anticipated. |
| **Special Populations** | - *Post‑menopausal women*: monitor estrogenic effects, breast cancer risk.
- *Men with low testosterone*: consider baseline PSA and prostate imaging.
- *Individuals with liver disease*: avoid hepatotoxic formulations.
- *Elderly with cognitive impairment*: watch for confusion or delirium. | Tailored monitoring schedules per risk profile; adjust dosage accordingly. |

---

## 4. Clinical Decision‑Making Flowchart

Below is a simplified textual flowchart that clinicians can follow when considering prescription sleep aids in older adults. (For visual representation, convert this into a diagram with decision nodes.)

```
START
│
├─ Are there non-pharmacologic options already tried?
│ ├─ Yes → Implement CBT‑I / sleep hygiene; reassess after 4–6 weeks.
│ └─ No → Proceed to pharmacologic consideration.
│
├─ Does the patient have any contraindications (e.g., severe COPD, narrow-angle glaucoma, uncontrolled bradycardia)?
│ ├─ Yes → Avoid sedative-hypnotics; consider alternative strategies.
│ └─ No → Continue.
│
├─ Which pharmacologic agent is most appropriate?
│ │
│ ├─ Non-benzodiazepine hypnotic (e.g., zolpidem) if short-term use (<2–4 weeks).
│ │ • Monitor for daytime sedation, paradoxical agitation.
│ │
│ ├─ Benzodiazepine (e.g., temazepam) if longer duration needed but risk of dependence acceptable.
│ │ • Use lowest effective dose; taper after 3–6 months.
│ │
│ └─ Other options: melatonin agonists, low-dose clonazepam for severe insomnia with anxiety component.
│
├── **Monitoring Plan**:
│ • Assess sleep quality weekly via subjective diary (sleep latency, awakenings).
│ • Check for adverse events: daytime sedation, falls risk, paradoxical agitation.
│ • Reevaluate after 4–6 weeks; consider tapering if improvement achieved.
│
└── **Follow‑up**:
• If insomnia persists >3 months or worsens, refer to a sleep specialist.
```

### 5. Key Points

- Use CBT‑I as the first‑line treatment for chronic insomnia; medication is supplementary and should be short‑term.
- Consider benzodiazepines only if CBT‑I is unavailable or ineffective; monitor closely for side effects.
- Avoid long‑acting hypnotics (e.g., zolpidem) in patients with risk of tolerance, sedation, or falls.

---

## References

1. **American Academy of Sleep Medicine (AASM).** Practice parameters: insomnia. *Sleep Med Rev.* 2020;64:101–108.
2. **National Institute for Health and Care Excellence (NICE).** Guideline NG80 – Insomnia. 2019.
3. **Bouchard M, et al.** Efficacy of benzodiazepine receptor agonists vs placebo for insomnia: systematic review and meta‑analysis. *Sleep* 2021;44(7):zsz123.
4. **Kumar A, et al.** Comparative effectiveness of benzodiazepines versus nonbenzodiazepines in treating insomnia. *J Clin Sleep Med.* 2019;15(10):1553‑1560.
5. **Taylor D, et al.** Long‑term safety and tolerability of Z-drugs: a cohort study. *Sleep Medicine* 2022;97:101‑108.

---

### Final Recommendation

1. **Prescribe a short‑acting Z-drug (e.g., zolpidem 5 mg)** for 3–4 weeks, with clear instructions on dosing and safety precautions.
2. **If inadequate or if side‑effects occur**, consider switching to a lower‑dose hypnotic such as temazepam 1–2 mg at bedtime, ensuring the patient is fully informed about risks of daytime sedation and rebound insomnia.

This balanced approach maximizes efficacy for sleep onset while minimizing the risk profile associated with benzodiazepine hypnotics.