Gonadal steroids in critical illness

The implementation of gonadal steroid therapy in the management of critically ill patients is not routine, though emerging clinical evidence may eventually change this. If critical illness can be conceptualized as an acute phase, a chronic phase, and a recovery phase, then a rational and evidence-based framework for the use of gonadal steroids can be constructed. In the acute and chronic phases, preclinical experimental data and clinical observational data argue against the use of androgens or anabolic steroid analogs. Investigational protocols may eventually demonstrate a beneficial role for estrogens (most likely with SERMs or STEARs) in these phases, but their use, however attractive, should be dissuaded at present. On the other hand, during the recovery phase, in which anabolism is critical for survival and INA setpoints have normalized, administration of anabolic agents, such as testosterone or oxandrolone, may be useful. Although this approach has not been supported by clinical evidence, a rational approach would be to limit these anabolic agents to those patients who have (1) no or minimal signs of active inflammation, (2) a reasonable expection for recovery with acceptable quality of life (subjective assessment), (3) biochemical hypotestosteronemia, (4) biochemical evidence of decreased nitrogen retention (increased urinary nitrogen excretion), and (5) no contraindications (prostate cancer, male breast cancer, elevated PSA requiring further evaluation).