0021-972X/99/$03.

00/0 The Journal of Clinical Endocrinology & Metabolism Copyright 1999 by The Endocrine Society

Vol. 84, No. 4 Printed in U.S.A.

Effects of Pharmacological Doses of Nandrolone Decanoate and Progressive Resistance Training in Immunodeficient Patients Infected with Human Immunodeficiency Virus*
FRED R. SATTLER, S. VICTORIA JAQUE, E. TODD SCHROEDER, CONNIE OLSON, MICHAEL P. DUBE, CARMEN MARTINEZ, WILLIAM BRIGGS, RICHARD HORTON, AND STANLEY AZEN
Department of Medicine, Division of Infectious Diseases (F.R.S., C.O., M.P.D.) and Endocrinology (C.M., R.H.), Department of Biokinesiology and Physical Therapy (S.V.J., E.T.S.), and Department of Preventive Medicine (S.A.), University of Southern California School of Medicine, Los Angeles CountyUniversity of Southern California Medical Center, Los Angeles, California 90033
ABSTRACT This nonplacebo-controlled, open label, randomized study was conducted to test the hypotheses that pharmacological doses of nandrolone decanoate would increase lean body tissue, muscle mass, and strength in immunodeficient human immunodeficiency virusinfected men, and that these effects would be enhanced with progressive resistance training (PRT). Thirty human immunodeficiency virus-positive men with fewer than 400 CD4 lymphocytes/mm3 were randomly assigned to receive weekly injections of nandrolone alone or in combination with supervised PRT at 80% of the one-repetition maximum three times weekly for 12 weeks. Total body weight increased significantly in both groups (3.2 2.7 and 4.0 2.0 kg, respectively; P 0.001), with increases due primarily to augmentation of lean tissue. Lean body mass determined by dual energy x-ray absorptiometry increased significantly more in the PRT group (3.9 2.3 vs. 5.2 5.7 kg, respectively; P 0.03). Body cell mass by bioelectrical impedance analysis increased significantly (P 0.001) in both groups (2.6 1.0 vs. 2.9 0.8 kg), but to a similar magnitude (P NS). Significant increases in cross-sectional area by magnetic resonance imaging of total thigh muscles (1538 767 and 1480 532 mm2), quadriceps (705 365 and 717 288 mm2), and hamstrings (842 409 and 771 295 mm2) occurred with both treatment strategies (P 0.001 for the three muscle areas); these increases were similar in both groups (P NS). By the one-repetition method, strength increased in both upper and lower body exercises, with gains ranging from 10.331% in the nandrolone group and from 14.4 53.0% in the PRT group (P 0.006 with one exception). Gains in strength were of significantly greater magnitude in the PRT group (P 0.005 for all comparisons), even after correction for lean body mass. Thus, pharmacological doses of nandrolone decanoate yielded significant gains in total weight, lean body mass, body cell mass, muscle size, and strength. The increases in lean body mass and muscular strength were significantly augmented with PRT. (J Clin Endocrinol Metab 84: 1268 1276, 1999)

OSS OF lean tissue and malnutrition portend a poor prognosis for patients with human immunodeficiency virus (HIV) (1). Although the incidence of aquired immune deficiency syndrome (AIDS) wasting syndrome has decreased with use of protease inhibitor-based regimens, weight losses as little as 0 10% are still associated with increased risks for fatality and occurrence of serious opportunistic infections (2). Thus, developing strategies to increase weight and especially the metabolically active body cell mass (BCM), which is comprised primarily of muscle and viscera, remains an important goal for the management of persons infected with HIV. Muscle appears to be an important reservoir of substrates for the BCM. In patients with advanced HIV, total protein turnover is increased (3, 4), myofibrillar breakdown is elevated (5), and increased quantities of glutamine and other
Received August 28, 1998. Revision received November 10, 1998. Accepted November 16, 1998. Address all correspondence and requests for reprints to: Dr. Fred R. Sattler, Los Angeles County-University of Southern California Medical Center, 1300 North Mission Road, Los Angeles, California 90033. * This work was supported by NIH grants (DK-49308 and NCRR GCRC MOI RR-43).

important amino acids are released from skeletal muscle to the systemic circulation (4). Muscle breakdown probably occurs to provide energy substrates for other metabolically active cells, such as intestinal and white blood cells (6). Indeed, it is estimated that approximately 109 CD4 lymphocytes are destroyed and replaced daily (10 100 times normal rates) in persons infected with HIV (7). Restoring and augmenting muscle mass should be important in maintaining muscle as a substrate reservoir for these metabolic functions. Muscle mass may be affected by several anabolic hormones in persons infected with HIV. In both HIV-positive men and women, levels of testosterone have been directly correlated with muscle mass (8, 9), and total testosterone levels have been in the hypogonadal range in nearly 40% and below age-matched control values in 70% of men infected with the virus (10, 11). The effects of testosterone on muscle are mediated by its regulatory actions on skeletal muscle protein synthesis (12) and through the local actions of insulin-like growth factor I (IGF-I) and IGF-I-binding proteins (13). In malnourished patients with HIV, GH blockade may result in low systemic levels of IGF-I (14) and, ultimately, tissue resistance to IGF-I and insulin (5). Treatment with protease inhibitors is also associated with insulin resistance

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(15, 16). Thus, abnormalities of several important anabolic hormones may contribute to the sarcopenic state in HIVinfected patients. Moreover, muscle mass is related to strength and physical activities of daily living (8, 17). As muscle mass and strength decline, activities such as ambulating, stair climbing, rising from a chair, and remaining independent become progressively more difficult. Lean tissue and muscle size are significantly increased with long term replacement doses of testosterone in hypogonadal men without HIV (18). In a recent controlled study of hypogonadal men with AIDS wasting, replacement therapy resulted in a 2.0-kg increase in lean tissue after 6 months, but no increase in self-reported exercise capacity (19). Relatively short term therapy (i.e. 10 weeks) with supraphysiological doses of testosterone resulted in more sizable increases in lean tissue, muscle size, and strength in healthy eugondal men (20). The effects of supraphysiological dosing were augmented with heavy resistance training (20), which also improves nitrogen balance (21) and can increase energy intake (22). However, it is not known whether effects of similar magnitude could be achieved in eugondal subjects infected with HIV who have increased resting energy expenditure and other metabolic abnormalities (2325). We therefore conducted a study with pharmacological doses of the anabolic steroid, nandrolone decanoate, to determine whether sizable increases in lean tissue, muscle size, and strength could be achieved in HIV-infected, immune-deficient men and whether these effects could be enhanced with progressive resistance training (PRT).
Subjects and Methods Study population
To be eligible for inclusion in the study, subjects had to be HIVseropositive men at least 18 yr of age with CD4 lymphocyte counts between 50 400/mm3 at screening, have stable weight (i.e. no prior weight loss 5% or weight variation 3% recorded in medical records in the prior 6 months), and have a body mass index of 20 27.5 kg/m2. Subjects were required to have HIV plasma ribonucleic acid levels at screening of less than 30,000 copies/mm3, be willing not to change antiretroviral therapy for the 12 weeks of study intervention, and have a dietary intake of calories greater than 0.8 of basal energy expenditure in the week before enrollment. Subjects could not have physical limitations that would interfere with rigorous strength testing and training and had to provide written informed consent approved by the institutional review board (research committee) of the Los Angeles CountyUniversity of Southern California Medical Center. Subjects were excluded from participation if they had evidence of active opportunistic infection, malignancy, or viral hepatitis. They could not have had fever (temperature, 100 F) or diarrhea (more than three stools per day) in the month before the study, have participated in weight training or vigorous exercise in the preceding 28 days, have a history of prostatic enlargement or active urinary symptoms, have a history or physical examination suggesting organic heart disease, or have a history of deep venous thrombosis. Subjects could not have used any anabolic therapies (e.g. human GH, testosterone, megestrol acetate, or synthetic steroids) in the preceding 6 months or have received immune modulating therapies (e.g. pentoxifylline, thalidomide, interferons, or interleukins). Finally, potential candidates were ineligible if their chest radiograph showed cardiomegaly or chronic lung disease, electrocardiogram revealed evidence of heart disease, fasting blood sugar was more than 127 mg/dL, alanine aminotransferase or alkaline phosphatase was greater than 3 times the upper limits of normal, prothrombin time was prolonged, or muscle enzymes (e.g. creatine kinase, aspartate aminotransferase, lactate dehydrogenase, and aldolase enzymes)

were more than 1.5 times the upper limit of normal within 14 days before enrollment.

Study interventions
This was an open label study in which all subjects received nandrolone decanoate (Deca Durabolin, Organon, Inc., West Orange, NJ) by weekly im injection for 16 weeks. Subjects were randomized to nandrolone alone or nandrolone plus PRT. The study design did not include a no treatment or placebo control group. The first dose of nandrolone was 200 mg, and the second dose was 400 mg. The dose was 600 mg for weeks 312. This dose was based on discussions with a number of body builders and our goal to study a relatively high end dose (but not maximum) commonly used for large anabolic effects and expected to be well tolerated in 60- to 70-kg men. Doses were reduced gradually during weeks 1316 (400, 200, 100, and 50 mg, respectively) to withdraw patients from pharmacological doses. After informed consent was provided, subjects were assigned according to a list of random numbers held by the study pharmacists to either a treatment strategy of sedentary activity without aerobic exercise or PRT for 12 weeks. Randomization was blocked in groups of four, so that there were two assignments to each of the regimens, and comparable numbers of subjects would be assigned to each arm of the study.

Exercise training regimen

PRT took place in the exercise physiology laboratory of the Department of Biokinesiology and Physical Therapy, University of Southern California (Los Angeles, CA). Subjects trained 3 times/week for 12 weeks (i.e. 36 total sessions) and performed various exercises for the upper and lower body, primarily using free weights. Exercises to strengthen the upper body included bench press, pull downs, military press, biceps curls, and triceps extensions. Lower body exercises included leg press, calf raises, leg curls, and leg extensions. After performing 1 warm-up set of 5 8 repetitions at 50% of the 1-repetition maximum (1RM) for each exercise, subjects performed 3 sets of 8 repetitions at 80% of the 1RM with the final set performed to failure. Each repetition was completed in 3 6 s. Subjects were allowed a 2-min rest period between all sets. To acclimate the subjects to the training program, work intensity began at 70% of the 1RM at baseline and was increased to 80% of the 1RM by the end of the second week of training, where it remained for the duration of the training period. The 1RM was assessed once every 2 weeks for all exercises to adjust the training load to maintain intensities at 80% of the 1RM.

Measurements
Dual energy x-ray absorptiometry. Lean body mass was determined by whole body dual energy x-ray absorptiometry (DEXA; QDR-1500, version 7.1 software, Hologic, Inc., Waltham, MA). Subjects were placed supine on the scanning table, with their arms and legs within the table pad guidelines. In accordance with manufacturers guidelines, the coefficient of variation was less than 1% for bone mineral density. All scans were analyzed by the same experienced technician and were performed at baseline and week 12 of the intervention. Body composition [total weight, lean body mass (LBM), and fat mass] was determined by the software provided by the manufacturer. Because total weight as determined by DEXA was highly correlated with measured weights using calibrated balance scales with patients undressed at baseline (r 0.992; P 0.001) and study week 12 (r 0.997; P 0.001), only total weights as determined by DEXA are reported. Bioelectrical impedance analysis (BIA). Body cell mass was assessed by BIA from measures of resistance and reactance with the RJL bioelectrical impedance analyzer (RJL Systems, Clinton, MI) and the manufacturers Fluid and Nutrition Analysis software (version 3.1a) at baseline and study week 12. Subjects were instructed to eat nothing after midnight the evening before their impedance values were measured. All subjects were asked to empty their bladders immediately before the measurements. Impedance values were determined with subjects comfortably resting in the supine position and clothed in a hospital gown (all jewelry was removed). Precision for repeated measurement of impedance values was less than 2%.

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Magnetic resonance imaging (MRI). Muscle cross-sectional area of the right thigh was determined by MRI (ACS II, Philips Medical Systems, Shelton, CT) at baseline and week 12 of study intervention. The T1 electron spin scans were used to determine total thigh muscle, quadriceps, and hamstring areas at the junctions of the proximal and middle third of the femur, and the middle and distal thirds of the femur. Measurements of three contiguous slices (i.e. the boundaries and those immediately adjacent on each side) at both the proximal and distal sites were summed and averaged to provide area values for the individual muscle compartments. The thickness of each MRI tissue slice was 6 mm, with 1 mm between slices. Areas of the femur, im fat, connective tissue, and blood vessels were removed using the software provided by the vendor before calculations of muscle areas (4.4 Gyroview, version 2.12, Philips Medical Systems). The coefficient of variation for repeated measures of muscle area was less than 0.2%. Strength. Before strength testing for each exercise, subjects warmed up by performing three repetitions of the exercise at 50%, 60%, 70%, and 85% of the projected maximal strength. Muscular strength was determined by the 1RM method on one occasion at baseline and again at study week 12 for the control group. The 1RM strength was defined as the heaviest weight that could be lifted through the range of motion only once, using proper form. In the PRT group, 1RM strength was determined for all of the weight-lifting exercises every 2 weeks, so that the training stimulus could be maintained at 80% of the 1RM. Nutritional assessment. A nutritionist (C.M.) instructed patients on how to complete 3-day food diaries. Dietary intake was recorded by each subject on 3 consecutive days, including 2 week days and 1 weekend day in the week before the baseline measurement, study week 6, and study week 12. Patients were counseled that the days should be chosen to include usual activities and typical eating patterns. They were advised to write down all foods and drinks (other than water) and the times when they were ingested and to be as specific as possible (brands, portion sizes, etc.). The nutritionist then reviewed the diary entries with the subjects for completeness and clarification at the appropriate study visits. This information was entered into the Nutritionist IV software (First Data Bank, San Bruno, CA) and analyzed for total calories and macronutrients.

to nandrolone plus PRT were not able to complete the 12 weeks of study intervention; 1 discontinued study therapy at week 10 because of an abdominal injury unrelated to PRT, and the other moved out of the country at week 7. At baseline, these 3 subjects were clinically similar to the other subjects who completed the study. Thus, the 30 subjects completing the week 12 measurements served as the primary study population. At baseline, both the group receiving only nandrolone decanoate and the group receiving nandrolone plus PRT were generally comparable (Table 1). Nearly all subjects were receiving HIV protease inhibitor-based regimens; the others were receiving therapy with at least one nucleoside analog and either lamivudine or a nonnucleoside HIV reverse transcriptase inhibitor. Of importance, the proportion with undetectable plasma HIV ribonucleic acid levels in the two treatment groups was also similar. Nutritional intake for the groups at baseline is shown in Table 2. Although patients assigned to receive only nandrolone without PRT tended to ingest more carbohydrate (P 0.05), there were no apparent differences when macronutrients were corrected for differences in LBM.
Body composition

Statistical considerations
The sample size was selected to demonstrate statistically significant differences in LBM by DEXA. For a comparison of means between the PRT and no resistance training groups, the projected mean change (desired effect) was a 3.0-kg increase in LBM, as previously achieved in HIV-negative subjects (20). Thus, the group receiving PRT would have a projected increase of 3.0 kg greater than the group not receiving PRT. For a significance at 0.05 (1-tailed) and power at 0.90, this required a sample size of 13/arm (total of 26) for a true sd of 2.6 kg or a sample size of 7/arm (total of 14) for a true sd of 2.0 kg. A 1-tailed test was chosen because of the lack of data that PRT decreases LBM. With a projected drop-out rate of 1525% (those not completing 12 weeks of study), the requisite total sample size was selected to be 33 subjects. Data were coded, quality was checked on several occasions, and data were analyzed using SPSS 8.0 software (SPSS, Inc., Chicago, IL). Distributions of continuous variables were checked for normality and were analyzed by appropriate parametric or nonparametric tests (Students t tests or Wilcoxon tests). Frequency data were analyzed using the 2 method. Because it was hypothesized that LBM changes would be greater with PRT, comparisons were made between groups at baseline and at 12 weeks for the change in the primary end point at the 5% level of significance using a one-tailed test. All other parameters were tested for significant differences at the 5% level using two-tailed tests.

Results Patients

Thirty-three patients were enrolled and initiated study interventions. One patient assigned to receive nandrolone without PRT was unable to perform strength tests at week 12 because of occupational hand injuries. Two patients assigned

Both the absolute and relative (percentage of variable) changes in body composition between baseline and study week 12 were analyzed. The results of paired DEXA scans and BIA measurements were available for all 30 study subjects. Body weight increased significantly (P 0.001) in subjects receiving only nandrolone (3.2 2.7 kg) and in those receiving nandrolone plus PRT (4.0 2.0 kg), but there was no difference in either absolute (P 0.40) or relative (P 0.27) increases between the groups (Table 3 and Fig. 1). Similarly, LBM increased significantly in both groups. The absolute change in LBM for those receiving PRT was statistically greater than that in patients not exercising (3.9 2.3 and 5.2 5.7 kg; P 0.03, one-tailed test), as was the relative increase in LBM with PRT (P 0.01, one-tailed test; Table 3 and Fig. 1). There was also a significant increase in BCM determined by BIA in the two groups (2.6 1.0 and 2.9 0.8 kg, respectively), but the magnitude of the increase was similar in the two groups (P 0.34 for absolute change; P 0.21 for relative change). Fat mass determined by DEXA was unchanged in subjects receiving nandrolone. In contrast, there was a significant (P 0.003) decrease in fat mass of 1.2 1.3 kg in the group receiving nandrolone plus PRT after 12 weeks of study intervention. Assessment of muscle area by MRI at both baseline and week 12 could only be performed in 13 subjects assigned to nandrolone alone and in 12 subjects in the nandrolone plus PRT group because of difficulties in obtaining access to the MRI scanner. The muscle area of the thigh increased significantly after 12 weeks in both treatment groups. Table 3 and Fig. 1 show that the increase was significant for the total (T) cross-sectional area of the thigh muscles as well as for the quadriceps (Q) and hamstring (H) muscle groups individually. Unlike for LBM, the group receiving PRT did not have a greater increase in either absolute (T, P 0.83; Q, P 0.92; H, P 0.63) or relative (T, P 0.87; Q, P 0.67; H, P 0.99)

NANDROLONE AND RESISTANCE TRAINING IN HIV

TABLE 1. Comparison of baseline characteristics of evaluable study patients
Clinical feature blood tests Nandrolone only group (n 15) Nandrolone PRT group (n 15) P valuea

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Age (yr) Ethnicity Hispanics Non-Hispanic Caucasians Non-Hispanic blacks Asian Pacific islanders Protease inhibitor therapy (no.) Indinavir Saquinavir Ritonavir Nelfinavir Saquinavir 2nd protease drugd Prior AIDS defining events (no.) Body mass index (kg/m2) CD4 lymphocyte count (no./mm3) Undetectable plasma HIV RNA Hemoglobin (g/dL) White blood count (no./mm3) Prothrombin time (s) Creatinine (mg/dL) Alanine aminotransferase (IU/L) Albumin (g/dL) Creatine kinase (U/L) Aldolase (mU/mL) Total testosterone (g/mL) Luteinizing hormone (U/mL)

37 8.2b 8 (53) 5 (33) 2 (13) 0 (0) 6 (40) 2 (13) 1 (7) 1 (7) 3 (20) 4 (27%) 24.9 2.2 216 96 10 (67%) 14.8 1.3 5500 1800 11.5 0.87 1.0 0.2 30 15 4.5 0.4 151 148 6.3 1.5 647 199 5.4 2.4

39 7.9 9 (60) 2 (13) 2 (13) 2 (13)

0.59 0.86c

0.94 5 (33) 0 (0) 2 (13) 1 (7) 3 (20) 2 (13%) 23.9 2.4 228 90 11 (73%) 14.3 1.5 4700 1200 11.5 0.60 1.0 0.2 42 29 4.6 0.4 190 137 6.3 2.0 573 156 5.7 2.9

0.24 0.26 0.73 0.56 0.42 0.16 0.98 0.57 0.15 0.65 0.46 0.96 0.27 0.77

Percentages are in parentheses. a By Students t test for continuous variables. b Mean 1 SD. c By 2 test for frequency data (percentage). d In both the nandrolone only and PRT groups, two subjects received saquinavir plus ritonavir, and one received saquinavir plus nelfinavir. TABLE 2. Baseline nutritional evaluation
Characteristic Nandrolone only (n 15) Nandrolone PRT (n 15) P value

Total energy intake (Cal/day) Energy intake (Cal/kg LBMday) Total protein intake (g/day) Protein intake (g/kg LBMday) Proportion protein intake (%) Total CHO intake (g/day) CHO intake (g/kg LBMday) Proportion CHO intake (%) Total fat intake (g/day) Fat intake (g/kg LBMday) Proportion fat intake (%)

3281 529 57.8 14.9 135.1 38.2 2.37 0.69 16.4 2.6 406.0 84.7 7.17 1.7 50.2 7.6 127.8 45.7 2.26 0.87 35.0 5.8

2772 512 50.0 14.5 123.9 40.3 2.26 0.70 18.7 6.0 328.2 120.7 6.02 2.2 47.3 10.4 106.0 32.6 1.96 0.63 35.2 6.5

0.14 0.16 0.44 0.67 0.19 0.05 0.12 0.39 0.15 0.28 0.92

cross-sectional muscle area than those receiving only nandrolone without exercise.
Strength

(P 0.005 for all comparisons) even after correction for LBM. Moreover, the increases in 1RM for several of these tests were several orders of magnitude greater for subjects assigned to PRT (Fig. 2).
Relationship of nutritional intake to changes in body composition and strength

Subjects in the PRT group completed 98.5% of their exercise training sessions. For each of the nine 1RM tests for strength (Table 4 and Fig. 2), absolute increases in kilograms and relative increases (percent increase from baseline) were significant for both treatment groups after 12 weeks of study intervention. In the nandrolone group, increases in strength ranged from 10.331%, and in the PRT group, they ranged from 14.4 53.0% (P 0.006 for all comparisons) with one exception; in the nandrolone group, there was no improvement in leg extension strength (P 0.21). Gains in strength were of significantly greater magnitude in the PRT group

There was no change in total caloric or macronutrient intake in study subjects from baseline to study weeks 6 and 12 (data not shown). Within the two treatment groups, there were no significant changes in energy or macronutrient intake during the course of the study (data not shown). In addition, individual changes in nutrient intake could not be related to changes in body composition or strength (data not shown).

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TABLE 3. Body composition at baseline and after 12 weeks of study therapy

Variable Nandrolone only (n 15) Nandrolone PRT (n 15) P valuea

BW (kg) Baseline Week 12 P valueb Lean body mass (kg) Baseline Week 12 P value Fat mass (kg) Baseline Week 12 P value Body cell mass (kg) Baseline Week 12 P value

73.3 6.47 76.5 7.08 0.001 57.1 5.52 61.0 6.50 0.001 13.6 3.02 13.1 2.46 0.25 29.5 3.16 32.1 3.57 0.001 n 12

70.9 11.1 74.9 10.4 0.001 55.3 7.07 60.5 7.12c 0.001 13.2 5.23 12.0 4.49 0.003 28.7 4.08 31.6 4.13 0.001 n 13 12,172 1,440 13,652 1,478 0.001 6,322 806 7,049 772 0.001 58,185 759 6,588 807 0.001

0.47 0.61 0.43 0.84 0.79 0.49 0.56 0.74

Total thigh muscle area (mm2) Baseline Week 12 P value Quadriceps muscle area (mm2) Baseline Week 12 P value Hamstring muscle area (mm2) Baseline Week 12 P value
a b

12,933 2,061 14,471 2,336 0.001 6,683 1,088 7,388 1,158 0.001 6,200 1,070 7,042 1,303 0.001

0.16 0.31 0.23 0.40 0.16 0.31

Difference between groups at baseline and week 12 by independent t test with two-tailed significance. Difference within groups between baseline and week 12 by paired Students t test. c P 0.03 (one-tailed) test for difference in the magnitude of increase between groups (data not shown).

Adverse events

None of the study subjects had any serious or treatmentterminating adverse events, and all reported feeling better while receiving study therapy. Several minor adverse events, however, were documented (Table 5). One patient in each group developed acneiform lesions. Both had histories of acne, and at the 12 week examination acneiform lesions were noted on the chest in both cases. One was treated with benzyol peroxide, and lesions regressed in both cases once nandrolone was discontinued. Eight patients in the nandrolone only group and four in the group assigned to PRT reported that the size of their testicles had decreased, but direct measurements of change in size were not made. None of the patients reported urinary symptoms or awareness of breast engorgement, had significant increases in blood pressure to hypertensive values, or developed edema (data not shown). Several changes in laboratory tests were noted. As anticipated, there was a mild increase in serum hemoglobin of 1.0 and 1.4 g/dL in the two treatment groups (P 0.001 for each change). Although there was a statistically significant increase in the alanine aminotransferase levels in the nandrolone only group, the average values at week 12 remained below the upper limits of normal (65 IU/L). In fact, no patient in either group had an increase in any liver test to greater than twice the upper level of normal for the laboratory, and there was no clinical evidence of hepatitis (e.g. liver enlargement or tenderness in any patient). There was a decrease in

the average serum albumin of 0.4 g/dL in the PRT group that reached significance (P 0.001). However, there was no apparent clinical cause for this decrease, as no patient developed an opportunistic infection or tumor, evidence of malabsorption, or significant decrease in nutritional intake during the conduct of the study. It was noteworthy that fasting serum total cholesterol and triglycerides did not increase. For the nandrolone only group, the decrease in total cholesterol reached statistical significance. High and low density cholesterol were not measured. Finally, CD4 lymphocyte counts remained unchanged in both groups during the 12-week course of therapy. Thus, there did not appear to be major deleterious adverse effects on serum lipids or immune function during the course of study.
Discussion

These results indicate that pharmacological doses of nandrolone decanoate can produce substantial increases in body mass in persons infected with HIV. After 12 weeks of study therapy, significant increases in total weight were demonstrable in both the group receiving only nandrolone and the group also receiving PRT; these changes were of similar magnitude (3.2 and 4.0 kg, respectively). Of importance, the increase in body weight was due primarily to enrichment of LBM in these two groups (3.9 and 5.2 kg, respectively). Moreover, there were significant increases in the cross-sectional

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TABLE 4. Upper and lower body strength at baseline and after 12 weeks
Strength tests (1 RM) Nandrolone only (n 15) Nandrolone PRT (n 15) P valuea

Upper body strength (kg) Bench press Baseline 59.7 13.9 Week 12 68.3 14.2 c P value 0.001 Military press Baseline 16.0 4.49 Week 12 18.6 4.47 P value 0.001 Bilateral biceps curl Baseline 28.9 5.65 Week 12 33.1 6.17 P value 0.001 Triceps curl Baseline 22.0 8.04 Week 12 27.4 6.31 P value 0.001 Pull downs Baseline 54.0 14.4 Week 12 58.5 11.8 P value 0.005 Lower body strength (kg) Leg press Baseline 159 25.8 Week 12 182 36.6 P value 0.002 Knee extension Baseline 62.4 18.1 Week 12 66.1 19.9 P value 0.21 Leg curl Baseline 25.9 6.31 Week 12 30.9 6.10 P value 0.001 Calf raises Baseline 127 30.5 Week 12 151 35.1 P value 0.006 FIG. 1. The upper panel shows the relative change (percentage) in total body weight, LBM, body cell mass, and fat mass measured from baseline to week 12 in the two treatment groups. The relative change in LBM was significantly greater in the nandrolone plus PRT group (P 0.013, by one-tailed test), but the differences between the groups for weight, body cell mass, and fat were not significant. The lower panel shows the relative change (percentage) in cross-sectional area of total thigh muscle, quadriceps, and hamstrings from baseline to week 12 in the two treatment groups. None of the reported relative changes for muscle area differed significantly between the two groups (P 0.05).

54.9 14.1 74.5 15.1b 0.001 14.5 3.51 21.6 4.84b 0.001 27.5 5.34 36.7 7.08b 0.001 20.0 6.99 29.3 8.06b 0.001 45.7 11.1 66.7 13.3b 0.001 134 21.6 208 36.8b 0.001 48.1 15.4 76.5 14.9b 0.001 23.0 6.46 35.8 6.77b 0.001 116 24.7 170 31.5b 0.001

0.35 0.26 0.31 0.09 0.50 0.15 0.46 0.46 0.09 0.08

0.007 0.07 0.03 0.12 0.22 0.05 0.31 0.14

a Difference between groups at baseline and week 12 by independent t test with two-tailed significance. b Absolute and relative changes were greater in the PRT group (P 0.04). c Difference within groups between baseline and week 12 by paired Students t test.

area of thigh muscles, providing further evidence that there was expansion of body cell mass and, importantly, muscle mass. This is the first study in persons infected with HIV to evaluate changes in body composition in response to anabolic steroids with or without resistance training and the first trial in subjects with HIV to use both DEXA and MRI to assess these changes. The only prior published study with nandrolone (100 mg every 2 weeks) involved 24 malnourished HIV-positive patients who gained 2.1 kg of LBM after a 16-week course of therapy (26). In that study, LBM was assessed by BIA, which measures primarily conductivity in ionically charged liquid medium (27). Thus, changes in fluid status, as may occur with anabolic steroids, may be inter-

preted as alterations in lean tissue by BIA. Although DEXA and MRI should be less sensitive to hydration, it is still possible that some of the increase in LBM and muscle size in our trial was also due to expansion of extracellular water, as we did not perform isotope dilution or other studies to directly assess changes in body water. However, none of the patients developed clinical edema, arthralgias, carpal tunnel syndrome, or hypertension. Moreover, the substantial increases in strength in the nandrolone only group even after correction for changes in LBM are greater than the expected gains from the limited familiarization (usually 10%) that may have occurred during the measurements taken at study week 12 (28). This suggests that there was a global increase in both the quantity and quality of functional muscle, providing further evidence that the significant increases in the lean tissue compartment were not due merely to accumulation of water. The increases in LBM were of similar magnitude to the

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TABLE 5. Adverse events and changes in laboratory tests during study therapy
Variable Nandrolone only (n 15) Nandrolone PRT (n 15) P valuea

Acne 1 (7) Testicular shrinkage 8 (53) Hemoglobin Baseline 14.8 1.3 Week 12 15.8 1.0 P valuec 0.001 Blood urea nitrogen Baseline 14 3.0 Week 12 13 7.0 P value 0.54 Alanine aminotransferase Baseline 30 15 Week 12 48 20 P value 0.002 Albumin Baseline 4.5 0.43 Week 12 4.3 0.26 P value 0.10 Total cholesterol Baseline 199 32.5 Week 12 187 38.5 P value 0.03 Triglycerides Baseline 240 201 Week 12 168 77.0 P value 0.10 CD4 lymphocyte counts Baseline 215 99 Week 12 237 117 P value 0.29

1 (7) 4 (27) 14.3 1.5 15.7 1.4 0.001 14 3.5 12 3.7 0.24 42 29 59 24 0.08 4.6 0.44 4.2 0.42 0.001 213 55.9 196 54.7 0.17 221 125 154 74.0 0.079 228 90 218 88 0.64

1.0 0.04 0.42 0.82 0.69 0.63 0.15 0.20 0.65 0.38 0.43 0.63 0.76 0.50 0.69 0.65

Percentages are given in parentheses. a Difference between groups at baseline and week 12 by independent t test with two-tailed significance. b Difference within groups between baseline and week 12 by paired Students t test.

FIG. 2. The upper panel shows the relative increase in strength measured by the 1RM corrected for LBM that was achieved by different exercises for the upper body muscles for the two treatment groups from baseline to week 12. The lower panel shows the relative increase in strength measured by the 1RM (also corrected for LBM) achieved by different exercises for the lower body muscles for the two treatment groups from baseline to week 12. All changes in relative strength were significantly greater in the nandrolone plus PRT group at the P 0.005 level, with the exception of triceps curls, where P 0.018.

increases of 3.5 kg (no exercise group) and 6.0 kg (PRT group) in LBM by underwater weighing in the study by Bhasin et al. involving healthy young men receiving 600 mg testosterone enanthate weekly for 10 weeks (20). Although their changes were slightly greater, subjects in the respective treatment groups in that study weighed 15% and 7.9% more at baseline than our subjects. Thus, the relative increases in LBM were nearly identical in the two studies. The studies were also similar in that the method of PRT was comparable, and the dietary intake of protein was prescribed to be 1.5 g/kgday (1.9 times the recommended daily allowance of 0.8 g/kgday) in their subjects and was 1.7 0.08 and 1.8 0.12 g/kgday in our respective treatment groups ingesting ad hoc diets. In a recent report involving subjects with AIDS wasting syndrome, 200 mg testosterone enanthate administered ev-

ery other week for 6 months resulted in a 2.0 3.2-kg increase in LBM as determined by DEXA (19). It may be that the increases in LBM were less in that study because subjects had advanced AIDS and were likely to have been more catabolic, as evidenced by low serum albumin levels and high HIV viral load (average gene copies exceeded 105/mL). It is also possible that there is a dose-response effect with anabolic steroids as proposed by Forbes (29), such that pharmacological doses will achieve greater effects than replacement doses. Although muscle mass can be quantitatively related to levels of serum testosterone in men and women with HIV (8, 9), studies are needed to determine whether there is a dose response for augmenting lean tissue during therapy with anabolic agents in this population. There appeared to be a positive interaction between nandrolone and PRT in increasing LBM. We doubt that PRT alone was responsible for the observed robust increase in LBM of 5.2 kg, although we did not include a PRT only group not receiving nandrolone. In the Bhasin study (20), a group of HIV-negative men who performed PRT without receiving testosterone only had a 2-kg increase in lean tissue, which was significantly less than the combined effect of testosterone plus PRT (i.e. 6.0-kg increase in fat-free mass). Similarly, in a study of HIV patients primarily without wasting, 8 weeks of PRT resulted in a 1.5-kg increase in lean tissue (30).

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The explanation for why there was not a significantly greater increase in muscle area determined by MRI in our patients receiving PRT than those assigned to no exercise is not clear. It is possible that there were greater increases in regions of the thigh muscles not selected for MRI scanning (31), there was a significant increase in total body musculature that was not significant for individual muscle groups, the PRT stimulus was not sufficient to further increase the large effects achieved by nandrolone alone, or there was a learning effect, with enhancement of muscle motor unit recruitment patterns. The substantial increases in strength corrected for LBM in the PRT group supports the latter consideration. It is also possible that there was enrichment of nonmuscular components of LBM, such as viscera. However, measurement of the metabolically active BCM by BIA showed comparable increases in the two groups, which suggests that the difference in LBM between the two groups determined by DEXA could have been due to other components of lean tissue than muscle or viscera (e.g. connective tissue). PRT per se stimulates skeletal muscle protein synthesis (32) and in persons with sarcopenia is known to stimulate muscle fiber hypertrophy (33). These effects are associated with increased strength and physical performance (33, 34) in frail patients without HIV. In patients with HIV who experienced a bout of Pneumocystis carinii pneumonia, a 6-week course of PRT produced increases in strength, combined arm and thigh girth, and body weight (35). By nature of the selection process, our patients did not have sarcopenia or impaired physical performance and had not recently experienced a serious opportunistic infection. Our results demonstrate that PRT may be a powerful stimulus to augment the effects of an anabolic agent to enhance lean tissue and strength in less advanced subjects with HIV. The mild decrease in serum albumin levels of 0.4 g/L (P 0.001) in the PRT group in the absence of decreased nutritional intake or intercurrent illnesses occurring over the course of the study is consistent with the acute phase reaction that occurs with strenuous eccentric muscular exercise (36). In addition, PRT is effective in reducing total (37) and abdominal obesity (38). Although anabolic steroids are also lipolytic (39), nandrolone alone resulted in a nonsignificant decrease in fat. However, there was a significant decrease in fat mass of 1.2 kg with PRT (P 0.003). The latter could prove important because protease inhibitor therapy for HIV is associated with increases in intraabdominal visceral fat (40), which are associated with increased risks for cardiovascular disease (41, 42). Finally, PRT was well tolerated by our subjects. Despite their chronic illness, use of multiple medications, and potential for intercurrent complications, our subjects were highly motivated and missed only 1.5% of the total training sessions despite a thrice weekly schedule for 3 months. Nandrolone decanoate was selected for the possibility that it might be better tolerated than testosterone. Nandrolone is not appreciably aromatized to estrogen (43, 44) and is believed to be associated with less breast engorgement and other androgenic effects that may occur with high doses of testosterone. In fact, nandrolone appeared to be well tolerated in our study. The only common adverse effect was the self-reported testicular shrinkage that would be expected with high doses of androgens suppressing LH and FSH se-

cretion. There were small, but significant, increases in serum hemoglobin of 1.0 and 1.4 g/dL in the two respective treatment groups, but the clinical relevance of this change is uncertain. There was also an approximately 1.5-fold increase in ALT in both groups, which reached statistical significance in the nandrolone only group. There was no clinical evidence of hepatitis, suggesting that these small increases may have been due to the im injections. Of importance, total cholesterol and triglycerides did not increase during the 12 weeks of study therapy. There was actually a significant decrease in total cholesterol documented in the nandrolone only group. However, this does not preclude the possibility that there was a decrease in the high density lipoprotein or an increase in the low density lipoprotein fractions of cholesterol. Although the high doses of nandrolone used in this study did not result in serious adverse events, the safety of such regimens should be confirmed in larger studies, and the risks of longer therapy are uncertain. In summary, treatment with high doses of nandrolone decanoate for 12 weeks was well tolerated and resulted in substantive anabolic effects in augmenting LBM and strength. A limitation of the study design was that a no treatment or placebo control group was not included. We hypothesize that the estimated effect of nandrolone would have been even greater if the treated patients were compared to a group of untreated subjects, because successful therapy with HAART is often associated with losses in LBM over as little as 100 150 days even in weight-stable patients (45). Of importance, the positive effects achieved with nandrolone alone were further enhanced with PRT. Whether lower doses of nandrolone would produce comparable effects or whether longer therapy would achieve greater benefits without additional risks for adverse events is uncertain. What is important is that the lean tissue compartment, in particular, muscle size and strength, can be enriched substantially despite chronic HIV infection, which is complicated by a number of metabolic disturbances. Additional studies will be needed to assess whether such treatment strategies can be effectively used to improve nutritional status and metabolism during periods of catabolic stress (e.g. major opportunistic infections), to increase physical performance in subjects with sarcopenia, and to facilitate improved and prolonged health in persons with HIV.
Acknowledgments
The authors thank the subjects who committed long hours in training and testing for this study, and Dr. Shalender Bhasin, Dr. Robert Wiswell, Dr. George Magree, Dr. Jaime LaTorre, Dr. Michael Terk, Dr. Thomas Lochner, Afrooz Afghani, Michael Mooney, James Brockman, Shellee James, and Blaine Horvath for their helpful suggestions and contributions.

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