Treatment of Patient with Significant IWL, Protein Energy Malnutrition, or in a Catabolic State
Initiate optimum daily nutrition
35 calories/kg body weight
1.5 g protein/kg body weight
High potency multivitamin, multi-mineral per day
Vitamin C, 1 g
Water/1 ml per calorie
Initiate Oral Oxandrolone Therapy
Once nutrition is adequate
After prostate cancer has been ruled out with prostate-specific antigen (PSA) After obtaining a normal PSA in patients over 50 yr of age Until body weight is restored and catabolic state resolved
Monitor Liver Function Tests
Decrease or temporarily stop oxandrolone if AST or ALT increases by more than three times normal value
Monitor Prothrombin Time
If patient on coumadin
In order to adjust coumadin dose downward if necessary
Provide Insulin Only in Acute Care Setting
If hyperglycemia is present due to the increased caloric intake Instead of decreasing calories
Provide Human Growth Hormone
Only if patient cannot take pills (oxandrolone)
In a dose of 5 to 10 mg sub q per day
Only if glucose levels can be carefully monitored
If patient also has evidence of a hypogonadal state Using testosterone enthanate 200 to 400 mg/IM every 2 weeks Or using testosterone undercanoate 80 mg p.o./twice a day After checking for prostate cancer more densely packed collagen with more fibroblasts and mononuclear cells. Anabolic steroids have also been shown to release the growth factor TGF-P by human fibroblasts.127 The mechanism of improved wound healing with the use of anabolic steroids is not yet defined. Stimulation of androgenic receptors on wound fibroblasts may well lead to a local release of growth factors.
In addition to androgenic activity, a number of potential side effects exist for this drug class. Some fluid retention will occur initially but is usually transient.109,112,113 Liver toxicity has been reported, ranging from a transient increase in aminotrans-ferases to jaundice, liver failure, and, rarely, liver tumor.128 The potential for liver change varies among anabolic steroids.112 Oxandrolone appears to be the safest. A recent 1 year study in elderly men given oxandrolone demonstrated only transient increases in aminotransferases.
A change in the lipid profile has been reported.129 Several studies have demonstrated a decrease in high-density lipoproteins, potentially increasing the risk of atherosclerosis. The lipid response differs among the drugs in this class.130
Anabolic steroids have been reported to increase the potency of coumadin, and coumadin dose often has to be decreased. Finally, this drug class is contraindicated in patients with prostate cancer, as this tumor is stimulated by androgenic receptors.112,113
Anabolic steroids are analogs of testosterone modified to increase anabolic and decrease androgenic side effects. All of these agents have been shown to increase lean body mass. In addition, there appears to be a direct wound healing effect. Side effects include liver dysfunction. Oxandrolone appears to be the most anabolic and safest anabolic steroid.
recommendations for pharmacologic manipulation
Anabolic hormones are necessary to maintain the necessary protein synthesis required for maintaining lean body mass, including wound healing, assuming the presence of adequate protein intake. However, endogenous levels of these hormones are decreased in acute and chronic illness and with increasing age, especially in the presence of a large wound.
The corroborating data, for the use of anabolic hormones, are excellent for more rapidly restoring protein synthesis and lean mass with lean mass loss. A high-calorie, high-protein diet is required.
Because lost lean mass caused by the stress response, aging, and malnutrition, retards wound healing, the ideal use of these agents is to more effectively restore anabolic activity. All these agents can cause complications specific to the hormone used, which needs to be considered.
There are also data that indicate a direct wound healing stimulating effect for some of these hormones. However, more clinical data need to be obtained before a recommendation can be made to use anabolic hormones to increase the rate of wound healing in the absence of a catabolic state or an existing lean mass loss. Oxandrolone is the agent of choice unless contraindicated with the presence of prostate cancer.
Three areas of research and development are indicated at this point. The first area is to better define the effect of all of these anabolic hormones on the various stages of wound healing. This information is needed in order to determine the indications for the use of the available anabolic hormones. It is possible that combination therapy would be more beneficial if it is determined that these agents have different modes of action.
The second area is the development of analogs of the anabolic hormones, which appear to have the most beneficial wound healing effects. The analogs would be developed to maximize wound healing activity and minimize complications.
The third area would be the development of a topical form of the anabolic hormones that demonstrate the most beneficial wound healing effects. The topical form would provide a direct wound healing benefit without the potential complications of systemic use.
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