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While I have learned a lot from many of the members of this board, I see many posts about liver issues relating to AAS use and thought maybe I could add some insight that might be helpful. As an introduction, I will say that I am not a clinician, but do work for a pharmaceutical company and am involved with a drug that has a high incidence of hepatotoxicity so I deal with these types of issues frequently. While I don’t claim to be an expert, I think I can at least help clarify some of the most important issues for board members. I also won’t quote a lot of studies to support what I write – if you don’t agree or believe in what I write, then so be it. Also, please note that I am not a doctor and am not dispensing medical advice. This is purely for your information.
How Hepatotoxic Are AAS?
The first point that should be made is that AAS can be used at relatively high doses and for long periods of time with little risk of serious injury to the liver. However, this assumes that proper monitoring is taking place, appropriate actions are taken if lab abnormalities or symptoms develop and other activities that may put an additional burden on the liver are limited or eliminated.
What Test Do I Need?
Always get an LFT through your physician. There is really no substitute for this. An LFT (Liver Function Test) will give you a snapshot of your liver’s health (it really does not measure the function of the liver, but that’s what the test is called). Primarily you will be looking at ALT and AST values (definitions are at the end of this post) which measure the serum liver enzyme concentrations present. The higher these values, the more liver cell damage that has occurred. Normal values for most labs are under 35 or under 50. The severity of hepatotoxicity is usually measured in what is termed multiples of ULN (Upper Limit of Normal). Therefore, a value of 100 would be termed 2 X ULN and would equate to a Grade II elevation. Anything under 5 x ULN is basically a Grade II elevation. 5-10 x ULN is a Grade III and a 10+ x ULN is a Grade IV, the most severe. However, concomitant symptomology may elevate the Grade regardless of lab values. Remember that intense weight training and high protein diets can cause a slight elevation in liver enzymes and should not be a concern. And, transient increases in lab values can occur during drug use that may resolve on their own and do not confer long term organ damage. What this means is that when you get your LFT (and you should) about 2 weeks into your cycle, this will give you an initial idea of how your liver is dealing with the drugs. Values below 100 should not be of real concern, but you will still want to get a follow-up LFT in about 4-6 weeks. What you don’t want to see is a significant elevation on the second test. If values are above 100, you need to think about lowering your dose, dropping a drug or stopping your cycle. In this situation you want to be vigilant in monitoring for hepatotoxic related symptoms and do a 2 week LFT follow up. For values above 250, I would strongly recommend stopping your cycle and again doing a 2 week LFT follow-up. Another thing to keep in mind is that most of your average FP/GP doctors out there have little experience in dealing with hepatotoxicity. It often scares them and they will certainly try to err on the side of safety. Often, you might see a slight elevation in lab values and your doctor will instantly tell you to stop your cycle. You will have to educate yourself and decide what is right for you.
Why Should I Be That Worried About My Liver?
Ok, the obvious answer is you only have one, it’s kind of an important organ and despite what many of us would like to believe, it is not very good at repairing itself once damage has been done. I will be as blunt as I can about this: If you are taking your Milk Thistle, Cranberry Extract, r-ALA, Tyler’s Liver Aid, and believe that this means you don’t need an LFT, you are kidding yourself. Yes, I know there are many of you that will say, “Hey, I took my super chelated magic yak sperm potion from Herbs R Us and didn’t have any problems”. However, with liver damage, you may not even know it is occurring. It is quite possible to have significant damage take place with no associated symptoms. Do this cycle after cycle and pretty soon your hepatic function is permanently impaired and no more AAS for you if you are lucky. If you are not lucky, it means all sorts of health problems with the prospect of a liver transplant later in your life.
What Symptoms Should I Watch For?
Here are some signs of liver trouble. If you experience any of these symptoms, please contact your doctor:
- Yellow discoloration of the skin or eyes.
- Abdominal swelling or severe abdominal pain.
- Prolonged itching of the skin.
- Very dark urine or pale stools-, or the passage of bloody or tar-like stools.
- Chronic fatigue, nausea or loss of appetite.
So Should I Use Liver Protectants or Not?
I can’t answer this really. Go ahead and take them if they make you feel better and they might have some real benefit. However, none of these supplements will prevent hepatic damage. At best (and I have yet to see the definitive studies on this), they may reduce damage to some small degree. That is just not good enough protection to fly blind without doing an LFT. Also, despite the regenerative claims made about certain supplements, there is no way any of them can regenerate liver cells faster than they can be destroyed by a hepatotoxic agent. This is about like standing in front of a tank with a fly swatter. Yeah, you can kill a fly, but the tank ain’t even going to know you are there when it rolls over you. The best application of these agents is probably post-cycle to allow your liver to heal. The company I work for recently spent many millions of dollars on a hepatic safety project related to our drug. This brought together leading hepatic specialists from around the world. The result was a treatment algorithm to be used in preventing, monitoring and treating hepatic related events with our drug. Guess what? Milk Thistle or its brethren never came up once and if they offered any real benefit, these guys would have been all over it. Bottom line is that you can certainly take them but do not depend on them for liver safety.
What Other Things Should I Be Concerned About?
No matter what cycle you are running, you are placing a burden on your liver. Everybody is different, so John might be able to run high dose dbols and 2 grams of test and hardly see a blip in his liver values. Tom might run low dose Deca and Sust and see his values go through the roof. There is no way to predict it – that is why they have this test. It ain’t fair but it’s the way it is. So, while on cycle try to be kind to your liver. The main culprits here are alcohol and acetaminophen (Tylenol or APAP). I would recommend completely eliminating these agents while on. I know not everyone will like this idea, but you can quickly screw yourself up if you are not careful. You would be shocked at the number of liver failures that occur each year because someone went out drinking heavy one night and decides to pop a few extra strength Tylenol to deal with the hangover. Good way to spend some time in the ER. Just saw a case in a hospital in Texas where a 16 year old girl (very low body weight) did this and ended up needing a liver transplant. Also, be aware that Tylenol is in all sorts of things. Read the label. Nytol has 1,0000mg per dose. At 4,000mg per day of Tylenol, in the absence of any other hepatic pressures, you will see liver enzyme elevations. For most of the pains we experience (sore muscles and joints) an NSAID (non-steroidal anti-inflammatory drug) is a much better choice. This includes good old aspirin, Advil/Motrin/ibuprofen and naproxen sodium. The last problem area is other prescription medications you may be on. Be honest with your doctor or pharmacist and make sure you know if another drug you are on could pose a problem. This includes drugs like Lipitor, certain antifungals, drugs for HIV, and many others.
I think the best way to look at this is that protecting your liver is just another way to ensure your long term gains. Letting liver damage occur will not only limit your future cycles, if not eliminate them, but can lead to long-term health problems up to and including transplant or death. I hope this article did not scare anyone. The intent is to make you informed enough so you can adequately monitor your liver so that it does not slow you down from achieving your goals. Being liver safe is not that hard, and for the vast majority of AAS users, they will be able to cycle safely with the appropriate monitoring and responsible actions.
Good lifting.
------------------------------------------
Definitions of ALT and AST:
Alanine aminotransferase (ALT) - a.k.a. Serum glutamate pyruvate transaminase (SGPT) Normal range: 0-34 U/L (The normal range does vary from one medical book to another) Enzyme is found in essentially the same tissues that have high concentrations of AST. In liver diseases, serum ALT elevations parallel those of AST, although slightly more acute hepatocellular parenchymal damage must occur to produce abnormal values. The ALT is relatively more abundant in hepatic tissue versus cardiac tissue than AST; however, the liver still contains 3.5 times more AST than ALT. Although serum levels of both AST and ALT become elevated whenever disease processes affect liver cell structure, the ALT is the more liver-specific enzyme. ALT serum concentrations are rarely increased except in parenchymal liver disease. Furthermore, elevations of ALT persist longer than those of AST.
Aspartate aminotransferase (AST) a.k.a. Serum glutamate oxaloacetic transaminase (SGOT) Normal value: 35 U/L (Normal range varies from medical book to another) AST is found in very large concentrations in heart and liver tissue, but only in moderate amounts in skeletal muscle, kidney, and pancreas. In cases of acute cellular injury to the heart or liver, the enzyme is released into the blood stream from the damaged cells and is presumably metabolized within the body. In clinical practice, AST determinations are used to evaluate myocardial injury and to diagnose and assess the prognosis of liver disease resulting from hepatocellular injury. Serum AST values are markedly elevated in patients with acute hepatic necrosis whether it is caused by viral hepatitis or a hepatotoxin. In these situations the serum concentrations of both AST and ALT will be increased, even before the appearance of clinical symptoms (e.g. jaundice). The AST and ALT serum concentrations may be increased by as much as 100 times the usual upper limit of normal in the presence of parenchymal liver disease. Patients with intrahepatic cholestasis or cirrhosis usually experience more moderate elevations of AST depending on the degree of cell necrosis taking place. The AST serum concentration is usually higher than that of ALT in patients with cirrhosis and the AST increase is usually about four to five times the upper limit of normal.
How Hepatotoxic Are AAS?
The first point that should be made is that AAS can be used at relatively high doses and for long periods of time with little risk of serious injury to the liver. However, this assumes that proper monitoring is taking place, appropriate actions are taken if lab abnormalities or symptoms develop and other activities that may put an additional burden on the liver are limited or eliminated.
What Test Do I Need?
Always get an LFT through your physician. There is really no substitute for this. An LFT (Liver Function Test) will give you a snapshot of your liver’s health (it really does not measure the function of the liver, but that’s what the test is called). Primarily you will be looking at ALT and AST values (definitions are at the end of this post) which measure the serum liver enzyme concentrations present. The higher these values, the more liver cell damage that has occurred. Normal values for most labs are under 35 or under 50. The severity of hepatotoxicity is usually measured in what is termed multiples of ULN (Upper Limit of Normal). Therefore, a value of 100 would be termed 2 X ULN and would equate to a Grade II elevation. Anything under 5 x ULN is basically a Grade II elevation. 5-10 x ULN is a Grade III and a 10+ x ULN is a Grade IV, the most severe. However, concomitant symptomology may elevate the Grade regardless of lab values. Remember that intense weight training and high protein diets can cause a slight elevation in liver enzymes and should not be a concern. And, transient increases in lab values can occur during drug use that may resolve on their own and do not confer long term organ damage. What this means is that when you get your LFT (and you should) about 2 weeks into your cycle, this will give you an initial idea of how your liver is dealing with the drugs. Values below 100 should not be of real concern, but you will still want to get a follow-up LFT in about 4-6 weeks. What you don’t want to see is a significant elevation on the second test. If values are above 100, you need to think about lowering your dose, dropping a drug or stopping your cycle. In this situation you want to be vigilant in monitoring for hepatotoxic related symptoms and do a 2 week LFT follow up. For values above 250, I would strongly recommend stopping your cycle and again doing a 2 week LFT follow-up. Another thing to keep in mind is that most of your average FP/GP doctors out there have little experience in dealing with hepatotoxicity. It often scares them and they will certainly try to err on the side of safety. Often, you might see a slight elevation in lab values and your doctor will instantly tell you to stop your cycle. You will have to educate yourself and decide what is right for you.
Why Should I Be That Worried About My Liver?
Ok, the obvious answer is you only have one, it’s kind of an important organ and despite what many of us would like to believe, it is not very good at repairing itself once damage has been done. I will be as blunt as I can about this: If you are taking your Milk Thistle, Cranberry Extract, r-ALA, Tyler’s Liver Aid, and believe that this means you don’t need an LFT, you are kidding yourself. Yes, I know there are many of you that will say, “Hey, I took my super chelated magic yak sperm potion from Herbs R Us and didn’t have any problems”. However, with liver damage, you may not even know it is occurring. It is quite possible to have significant damage take place with no associated symptoms. Do this cycle after cycle and pretty soon your hepatic function is permanently impaired and no more AAS for you if you are lucky. If you are not lucky, it means all sorts of health problems with the prospect of a liver transplant later in your life.
What Symptoms Should I Watch For?
Here are some signs of liver trouble. If you experience any of these symptoms, please contact your doctor:
- Yellow discoloration of the skin or eyes.
- Abdominal swelling or severe abdominal pain.
- Prolonged itching of the skin.
- Very dark urine or pale stools-, or the passage of bloody or tar-like stools.
- Chronic fatigue, nausea or loss of appetite.
So Should I Use Liver Protectants or Not?
I can’t answer this really. Go ahead and take them if they make you feel better and they might have some real benefit. However, none of these supplements will prevent hepatic damage. At best (and I have yet to see the definitive studies on this), they may reduce damage to some small degree. That is just not good enough protection to fly blind without doing an LFT. Also, despite the regenerative claims made about certain supplements, there is no way any of them can regenerate liver cells faster than they can be destroyed by a hepatotoxic agent. This is about like standing in front of a tank with a fly swatter. Yeah, you can kill a fly, but the tank ain’t even going to know you are there when it rolls over you. The best application of these agents is probably post-cycle to allow your liver to heal. The company I work for recently spent many millions of dollars on a hepatic safety project related to our drug. This brought together leading hepatic specialists from around the world. The result was a treatment algorithm to be used in preventing, monitoring and treating hepatic related events with our drug. Guess what? Milk Thistle or its brethren never came up once and if they offered any real benefit, these guys would have been all over it. Bottom line is that you can certainly take them but do not depend on them for liver safety.
What Other Things Should I Be Concerned About?
No matter what cycle you are running, you are placing a burden on your liver. Everybody is different, so John might be able to run high dose dbols and 2 grams of test and hardly see a blip in his liver values. Tom might run low dose Deca and Sust and see his values go through the roof. There is no way to predict it – that is why they have this test. It ain’t fair but it’s the way it is. So, while on cycle try to be kind to your liver. The main culprits here are alcohol and acetaminophen (Tylenol or APAP). I would recommend completely eliminating these agents while on. I know not everyone will like this idea, but you can quickly screw yourself up if you are not careful. You would be shocked at the number of liver failures that occur each year because someone went out drinking heavy one night and decides to pop a few extra strength Tylenol to deal with the hangover. Good way to spend some time in the ER. Just saw a case in a hospital in Texas where a 16 year old girl (very low body weight) did this and ended up needing a liver transplant. Also, be aware that Tylenol is in all sorts of things. Read the label. Nytol has 1,0000mg per dose. At 4,000mg per day of Tylenol, in the absence of any other hepatic pressures, you will see liver enzyme elevations. For most of the pains we experience (sore muscles and joints) an NSAID (non-steroidal anti-inflammatory drug) is a much better choice. This includes good old aspirin, Advil/Motrin/ibuprofen and naproxen sodium. The last problem area is other prescription medications you may be on. Be honest with your doctor or pharmacist and make sure you know if another drug you are on could pose a problem. This includes drugs like Lipitor, certain antifungals, drugs for HIV, and many others.
I think the best way to look at this is that protecting your liver is just another way to ensure your long term gains. Letting liver damage occur will not only limit your future cycles, if not eliminate them, but can lead to long-term health problems up to and including transplant or death. I hope this article did not scare anyone. The intent is to make you informed enough so you can adequately monitor your liver so that it does not slow you down from achieving your goals. Being liver safe is not that hard, and for the vast majority of AAS users, they will be able to cycle safely with the appropriate monitoring and responsible actions.
Good lifting.
------------------------------------------
Definitions of ALT and AST:
Alanine aminotransferase (ALT) - a.k.a. Serum glutamate pyruvate transaminase (SGPT) Normal range: 0-34 U/L (The normal range does vary from one medical book to another) Enzyme is found in essentially the same tissues that have high concentrations of AST. In liver diseases, serum ALT elevations parallel those of AST, although slightly more acute hepatocellular parenchymal damage must occur to produce abnormal values. The ALT is relatively more abundant in hepatic tissue versus cardiac tissue than AST; however, the liver still contains 3.5 times more AST than ALT. Although serum levels of both AST and ALT become elevated whenever disease processes affect liver cell structure, the ALT is the more liver-specific enzyme. ALT serum concentrations are rarely increased except in parenchymal liver disease. Furthermore, elevations of ALT persist longer than those of AST.
Aspartate aminotransferase (AST) a.k.a. Serum glutamate oxaloacetic transaminase (SGOT) Normal value: 35 U/L (Normal range varies from medical book to another) AST is found in very large concentrations in heart and liver tissue, but only in moderate amounts in skeletal muscle, kidney, and pancreas. In cases of acute cellular injury to the heart or liver, the enzyme is released into the blood stream from the damaged cells and is presumably metabolized within the body. In clinical practice, AST determinations are used to evaluate myocardial injury and to diagnose and assess the prognosis of liver disease resulting from hepatocellular injury. Serum AST values are markedly elevated in patients with acute hepatic necrosis whether it is caused by viral hepatitis or a hepatotoxin. In these situations the serum concentrations of both AST and ALT will be increased, even before the appearance of clinical symptoms (e.g. jaundice). The AST and ALT serum concentrations may be increased by as much as 100 times the usual upper limit of normal in the presence of parenchymal liver disease. Patients with intrahepatic cholestasis or cirrhosis usually experience more moderate elevations of AST depending on the degree of cell necrosis taking place. The AST serum concentration is usually higher than that of ALT in patients with cirrhosis and the AST increase is usually about four to five times the upper limit of normal.
