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, 49 (9), 1195-1204

Severe and Protracted Cholestasis in 44 Young Men Taking Bodybuilding Supplements: Assessment of Genetic, Clinical and Chemical Risk Factors


Severe and Protracted Cholestasis in 44 Young Men Taking Bodybuilding Supplements: Assessment of Genetic, Clinical and Chemical Risk Factors

Andrew Stolz et al. Aliment Pharmacol Ther.


Background: Bodybuilding supplements can cause a profound cholestatic syndrome.

Aim: To describe the drug-Induced liver injury network's experience with liver injury due to bodybuilding supplements.

Methods: Liver injury pattern, severity and outcomes, potential genetic associations, and exposure to anabolic steroids by product analysis were analysed in prospectively enrolled subjects with bodybuilding supplement-induced liver injury with causality scores of probable or higher.

Results: Forty-four males (mean age 33 years) developed liver injury with a median latency of 73 days. Forty-one per cent presented with hepatocellular pattern of liver injury as defined by the R > 5 ([Fold elevation of ALT] ÷ [Fold elevation of Alk Phos] (mean, range = 6.4, 0.5-31.4, n = 42) despite all presenting with clinical features of cholestatic liver injury (100% with jaundice and 84% with pruritus). Liver biopsy (59% of subjects) demonstrated a mild hepatitis and profound cholestasis in most without bile duct injury, loss or fibrosis. Seventy-one per cent were hospitalised, and none died or required liver transplantation. In some, chemical analysis revealed anabolic steroid controlled substances not listed on the label. No enrichment of genetic variants associated with cholestatic syndromes was found, although mutations in ABCB11 (present in up to 20%) were significantly different than in ethnically matched controls.

Conclusions: Patients with bodybuilding supplements liver injury uniformly presented with cholestatic injury, which slowly resolved. The ingested products often contained anabolic steroids not identified on the label, and no enrichment in genetic variants was found, indicating a need for additional studies.

Conflict of interest statement

Conflict of interest disclosure

Dr. Chalasani has ongoing consulting activities (or had in preceding 12 months) with NuSirt, Abbvie, Eli Lilly, Afimmune (DS Biopharma), Tobira (Allergan), Madrigal, Shire, Cempra, Ardelyx, Gen Fit and Amarin. These consulting activities are generally in the areas of non-alcoholic fatty liver disease and drug hepatotoxicity. Dr. Chalasani receives research grant support from Intercept, Lilly, Gilead, Galectin Therapeutics and Cumberland where his institution receives the funding. Over the last decade, Dr. Chalasani has served as a paid consultant to more than 30 pharmaceutical companies and these outside activities have regularly been disclosed to his institutional authorities. Dr. Fontana has received research support from BMS, Janssen, and Gilead and served as a consultant to Alynam. Dr. Bonkovsky serves as consultant to Alnylam Pharma, Blue, Mitsubishi-Tanabe, Moderna, Recordati rare Chemicals, and Stoke. He receives support for clinical studies from Alnylam and Gilead Sciences in the area of porphyrias. Dr. Bonkovsky serves as a member of the Medical and Scientific Advisory Boards of the American Porphyria Foundation and the Iron Disorders Institute. Dr. Seeff is presently a consultant to Abbvie and Intercept and was a consultant to Cempra Drs. Barnhart, Gu, Stolz, Hayashi, Navarro, Serrano, Kleiner, Cirruli, Avula, and Hoofnagle have no conflicts of interest to disclose.

Comment in

  • Editorial: bodybuilders beware.
    Feldman DM, Jacobson IM. Feldman DM, et al. Aliment Pharmacol Ther. 2019 Jun;49(12):1530. doi: 10.1111/apt.15270. Aliment Pharmacol Ther. 2019. PMID: 31134650 No abstract available.

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