{
 "version": 5,
 "reviewed": "2026-10-04",
 "_schema": {
  "purpose": "Shared stack-interaction rules for the optipin.app stack checker, the X-and-Y pair pages and the OptiPin app. One file, read by all three; the app copy at TRT/TRT/Resources/stack-rules.json must be byte-identical.",
  "compoundResolution": "A user's compound resolves to an id: either a medication-education.json id (which carries compoundClass) or an id from this file's `compounds` list (no compoundClass; matched by tags). Names resolve by normalizing both sides (lowercase, every run of non [a-z0-9] characters becomes one space, trimmed) and matching an education entry's name, or a `compounds` alias as a whole-word phrase: (' ' + name + ' ') contains (' ' + alias + ' ').",
  "selector": "A selector matches one compound if ANY of: its id is in `ids`; it is a `compounds` entry carrying any tag in `tags`; or it has a compoundClass satisfying `class`. `class` maps a compoundClass field to either a boolean (equality) or an array of allowed lowercase string values; all listed fields must hold. `minCount` (default 1) is the number of DISTINCT stack compounds that must match the selector.",
  "rule": "A rule fires when every selector in `match.all` is satisfied and no selector in `match.none` matches even one compound. When several selectors are satisfied by the same single compound, that is allowed; rules that need two different compounds use disjoint selectors.",
  "flaggedCompounds": "Display the union of compounds that matched the `all` selectors, so the reader sees which compound put the flag there.",
  "tiers": "interaction = drug-label or pharmacokinetic evidence for the pair; load = additive class effect on one organ or marker, the combination itself inferred; thin = mechanism or absence of data only, shown as such.",
  "neverInThisFile": "Doses, ratios, schedules, 'safe' or 'fine to stack' verdicts, ancillary or hepatoprotective protocols, PCT recipes, recreational insulin, DNP or diuretic combinations, canary ids.",
  "management": "Optional {text, basis: one of the five tags (see basis), sources[]}. How a finding is usually handled, by class with at most one example and always a referral (clinician, prescriber or clinic). Never a dose, a dose direction or size, a schedule or a protocol.",
  "basis": "Every rule has `basis` (the evidence for its main claim) and every `management` has its own `basis`, one of five tags: label = a drug's US prescribing information says it; clinical = clinical evidence: guidelines, clinical reviews or studies in people; off-label = widely used outside the label, documented by a user survey or review (never a forum post alone); mechanism = follows from chemistry, receptor or animal data, not shown in people; anecdotal = community reports only. For load rules the basis describes the class effect; the tier already says the combination is inferred. Off-label and anecdotal lines never carry a dose; off-label lines end in a clinician referral; anecdotal lines say the claim is reported or community-based; every tag except anecdotal needs a source."
 },
 "compounds": [
  {
   "id": "tamoxifen",
   "name": "Tamoxifen",
   "aliases": [
    "tamoxifen",
    "nolvadex",
    "soltamox"
   ],
   "tags": [
    "serm"
   ]
  },
  {
   "id": "letrozole",
   "name": "Letrozole",
   "aliases": [
    "letrozole",
    "femara"
   ],
   "tags": [
    "aromatase-inhibitor"
   ]
  },
  {
   "id": "warfarin",
   "name": "Warfarin",
   "aliases": [
    "warfarin",
    "coumadin",
    "jantoven"
   ],
   "tags": [
    "vitamin-k-antagonist"
   ]
  },
  {
   "id": "glipizide",
   "name": "Glipizide",
   "aliases": [
    "glipizide",
    "glucotrol"
   ],
   "tags": [
    "sulfonylurea"
   ]
  },
  {
   "id": "glyburide",
   "name": "Glyburide",
   "aliases": [
    "glyburide",
    "glibenclamide"
   ],
   "tags": [
    "sulfonylurea"
   ]
  },
  {
   "id": "glimepiride",
   "name": "Glimepiride",
   "aliases": [
    "glimepiride",
    "amaryl"
   ],
   "tags": [
    "sulfonylurea"
   ]
  },
  {
   "id": "naltrexone",
   "name": "Naltrexone (oral)",
   "aliases": [
    "naltrexone",
    "revia"
   ],
   "tags": []
  },
  {
   "id": "clenbuterol",
   "name": "Clenbuterol",
   "aliases": [
    "clenbuterol",
    "clen"
   ],
   "tags": [
    "sympathomimetic"
   ]
  },
  {
   "id": "ephedrine",
   "name": "Ephedrine (incl. ECA stacks)",
   "aliases": [
    "ephedrine",
    "ephedra",
    "eca"
   ],
   "tags": [
    "sympathomimetic"
   ]
  },
  {
   "id": "liothyronine",
   "name": "T3 (Liothyronine)",
   "aliases": [
    "liothyronine",
    "t3",
    "cytomel"
   ],
   "tags": [
    "thyroid-hormone"
   ]
  },
  {
   "id": "finasteride",
   "name": "Finasteride",
   "aliases": [
    "finasteride",
    "propecia",
    "proscar"
   ],
   "tags": [
    "5ar-inhibitor"
   ]
  },
  {
   "id": "dutasteride",
   "name": "Dutasteride",
   "aliases": [
    "dutasteride",
    "avodart"
   ],
   "tags": [
    "5ar-inhibitor"
   ]
  },
  {
   "id": "rad-140",
   "name": "RAD-140 (Testolone)",
   "aliases": [
    "rad 140",
    "rad140",
    "testolone"
   ],
   "tags": [
    "sarm"
   ]
  },
  {
   "id": "lgd-4033",
   "name": "LGD-4033 (Ligandrol)",
   "aliases": [
    "lgd 4033",
    "lgd4033",
    "ligandrol"
   ],
   "tags": [
    "sarm"
   ]
  },
  {
   "id": "ostarine",
   "name": "Ostarine (MK-2866)",
   "aliases": [
    "ostarine",
    "mk 2866",
    "enobosarm"
   ],
   "tags": [
    "sarm"
   ]
  },
  {
   "id": "s-23",
   "name": "S-23",
   "aliases": [
    "s 23"
   ],
   "tags": [
    "sarm"
   ]
  },
  {
   "id": "andarine",
   "name": "Andarine (S4)",
   "aliases": [
    "andarine"
   ],
   "tags": [
    "sarm"
   ]
  },
  {
   "id": "npp",
   "name": "NPP (Nandrolone Phenylpropionate)",
   "aliases": [
    "npp",
    "nandrolone phenylpropionate"
   ],
   "tags": [
    "nandrolone",
    "19-nor"
   ]
  },
  {
   "id": "nandrolone-cypionate",
   "name": "Nandrolone Cypionate",
   "aliases": [
    "nandrolone cypionate"
   ],
   "tags": [
    "nandrolone",
    "19-nor"
   ]
  },
  {
   "id": "trestolone",
   "name": "Trestolone (MENT)",
   "aliases": [
    "trestolone",
    "ment"
   ],
   "tags": [
    "19-nor"
   ]
  },
  {
   "id": "estradiol-other",
   "name": "Estradiol (other forms)",
   "aliases": [
    "estradiol valerate oral",
    "estradiol acetate",
    "estradiol sublingual",
    "estradiol benzoate",
    "estradiol enanthate",
    "estradiol cypionate"
   ],
   "tags": [
    "estrogen"
   ]
  }
 ],
 "rules": [
  {
   "id": "tamoxifen-aromatase-inhibitor",
   "tier": "interaction",
   "basis": "label",
   "audience": [
    "anabolic",
    "trt"
   ],
   "match": {
    "all": [
     {
      "ids": [
       "tamoxifen"
      ]
     },
     {
      "ids": [
       "anastrozole",
       "letrozole"
      ]
     }
    ]
   },
   "title": "Tamoxifen lowers anastrozole and letrozole levels",
   "summary": "Tamoxifen lowers anastrozole blood levels by about 27% and letrozole by about 38%. The anastrozole and tamoxifen labels say not to combine them, mainly because the pair showed no added benefit in breast-cancer trials.",
   "whyItMatters": "In those studies (postmenopausal women) estradiol suppression held despite the lower levels, so what this means for estradiol in men is not known.",
   "markers": [
    "Estradiol (sensitive assay) before starting and again after any change to either drug"
   ],
   "seekCare": [],
   "evidence": "Strong for the drop in drug levels (labels plus pharmacokinetic studies); the same studies found no significant effect on estradiol suppression.",
   "sources": [
    {
     "citation": "Arimidex (anastrozole) US prescribing information, section 7 Drug Interactions (7.1 Tamoxifen, 7.2 Estrogen), DailyMed",
     "url": "https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=acbfaaa9-503c-4691-9828-76a7146ed6de",
     "verifiedOn": "2026-10-04"
    },
    {
     "citation": "Soltamox (tamoxifen citrate) US prescribing information, section 4 Contraindications and section 7 (7.1 Aromatase Inhibitors, 7.2 Warfarin), DailyMed",
     "url": "https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=1e6ff055-590c-41e6-9530-1fdf04cdbd02",
     "verifiedOn": "2026-10-04"
    },
    {
     "citation": "Femara (letrozole) US prescribing information, section 7 Drug Interactions (Tamoxifen: letrozole levels down 38%), DailyMed",
     "url": "https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=82b77d74-085f-45ac-a7dd-1f5c038bf406",
     "verifiedOn": "2026-10-04"
    },
    {
     "citation": "Dowsett M, et al. Pharmacokinetics of anastrozole and tamoxifen alone, and in combination, during adjuvant endocrine therapy for early breast cancer in postmenopausal women. Br J Cancer 2001;85(3):317-324.",
     "url": "https://pubmed.ncbi.nlm.nih.gov/11487258/",
     "verifiedOn": "2026-10-04"
    },
    {
     "citation": "Dowsett M, et al. Impact of tamoxifen on the pharmacokinetics and endocrine effects of the aromatase inhibitor letrozole in postmenopausal women with breast cancer. Clin Cancer Res 1999;5(9):2338-2343.",
     "url": "https://pubmed.ncbi.nlm.nih.gov/10499602/",
     "verifiedOn": "2026-10-04"
    }
   ],
   "management": {
    "text": "The labels advise against using the two together; a clinician decides which one fits.",
    "basis": "label",
    "sources": [
     {
      "citation": "Arimidex (anastrozole) US prescribing information, sections 7.1 Tamoxifen and 7.2 Estrogen, DailyMed.",
      "url": "https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=acbfaaa9-503c-4691-9828-76a7146ed6de",
      "verifiedOn": "2026-10-04"
     },
     {
      "citation": "Soltamox (tamoxifen citrate) US prescribing information, section 7.1 Aromatase Inhibitors (\"should be avoided in all patients\"; letrozole \"not recommended\"), DailyMed.",
      "url": "https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=1e6ff055-590c-41e6-9530-1fdf04cdbd02",
      "verifiedOn": "2026-10-04"
     }
    ]
   }
  },
  {
   "id": "tamoxifen-warfarin",
   "tier": "interaction",
   "basis": "label",
   "audience": [
    "anabolic",
    "trt"
   ],
   "match": {
    "all": [
     {
      "ids": [
       "tamoxifen"
      ]
     },
     {
      "ids": [
       "warfarin"
      ]
     }
    ]
   },
   "title": "Tamoxifen strengthens warfarin",
   "summary": "The tamoxifen label warns of a marked increase in warfarin's anticoagulant effect and lists the pair as a contraindication in some settings. Whoever manages the warfarin needs to know about the tamoxifen.",
   "whyItMatters": "Over-anticoagulation causes bleeding that may not be obvious until it is serious.",
   "markers": [
    "INR, checked by the clinic managing warfarin, more often whenever tamoxifen starts or stops"
   ],
   "seekCare": [
    "Unusual bruising or bleeding gums",
    "Black or bloody stools, or blood in urine",
    "Coughing or vomiting blood (emergency services)"
   ],
   "evidence": "Strong: drug-label contraindication and interaction.",
   "sources": [
    {
     "citation": "Soltamox (tamoxifen citrate) US prescribing information, section 4 Contraindications and section 7 (7.1 Aromatase Inhibitors, 7.2 Warfarin), DailyMed",
     "url": "https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=1e6ff055-590c-41e6-9530-1fdf04cdbd02",
     "verifiedOn": "2026-10-04"
    }
   ],
   "management": {
    "text": "The clinic managing warfarin usually handles this by checking INR more closely and adjusting the anticoagulant; tell them before it starts or stops.",
    "basis": "label",
    "sources": [
     {
      "citation": "Soltamox (tamoxifen citrate) US prescribing information, section 7.2 Warfarin (\"Closely monitor coagulation indices\"), DailyMed.",
      "url": "https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=1e6ff055-590c-41e6-9530-1fdf04cdbd02",
      "verifiedOn": "2026-10-04"
     }
    ]
   }
  },
  {
   "id": "androgen-warfarin",
   "tier": "interaction",
   "basis": "label",
   "audience": [
    "anabolic",
    "trt"
   ],
   "match": {
    "all": [
     {
      "class": {
       "baseClass": [
        "androgen"
       ],
       "hpgSuppression": [
        "mild",
        "moderate",
        "strong",
        "total"
       ]
      }
     },
     {
      "ids": [
       "warfarin"
      ]
     }
    ]
   },
   "title": "Androgens can strengthen warfarin",
   "summary": "The testosterone label says androgens may increase sensitivity to oral anticoagulants. Whoever manages the warfarin needs to know about every androgen in the stack.",
   "whyItMatters": "Starting, stopping or changing an androgen can move INR without any change to the warfarin.",
   "markers": [
    "INR, checked by the clinic managing warfarin, after any androgen is started, stopped or changed"
   ],
   "seekCare": [
    "Unusual bruising or bleeding gums",
    "Black or bloody stools, or blood in urine",
    "Coughing or vomiting blood (emergency services)"
   ],
   "evidence": "Moderate: drug-label precaution for testosterone, applied to androgens as a class by the label itself. The label predates the newer direct oral anticoagulants and speaks only to oral anticoagulants of its era. DHEA, an over-the-counter precursor the label does not address, is left out.",
   "sources": [
    {
     "citation": "Depo-Testosterone (testosterone cypionate) US prescribing information, Precautions: Drug interactions, DailyMed",
     "url": "https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=cfbb53d4-b868-4a28-8436-f9112eb01c39",
     "verifiedOn": "2026-10-04"
    }
   ],
   "management": {
    "text": "The clinic managing warfarin usually handles this by checking INR more closely and adjusting the anticoagulant; tell them before it starts or stops.",
    "basis": "label",
    "sources": [
     {
      "citation": "Depo-Testosterone (testosterone cypionate) US prescribing information, Precautions: Drug interactions (\"Dosage of the anticoagulant may require reduction\"; \"may decrease blood glucose and, therefore, insulin requirements\"), DailyMed.",
      "url": "https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=cfbb53d4-b868-4a28-8436-f9112eb01c39",
      "verifiedOn": "2026-10-04"
     }
    ]
   }
  },
  {
   "id": "androgen-insulin",
   "tier": "interaction",
   "basis": "label",
   "audience": [
    "anabolic",
    "trt"
   ],
   "match": {
    "all": [
     {
      "class": {
       "baseClass": [
        "androgen"
       ],
       "hpgSuppression": [
        "mild",
        "moderate",
        "strong",
        "total"
       ]
      }
     },
     {
      "ids": [
       "insulin-rapid",
       "insulin-regular",
       "insulin-glargine",
       "insulin-degludec"
      ],
      "tags": [
       "sulfonylurea"
      ]
     }
    ]
   },
   "title": "Androgens can lower blood glucose on diabetes medication",
   "summary": "The testosterone label notes that in people with diabetes, androgens may lower blood glucose and so reduce insulin needs. On insulin or a sulfonylurea it could raise the chance of a low.",
   "whyItMatters": "A glucose-lowering regimen that was right before the androgen can overshoot after it.",
   "markers": [
    "Home glucose readings, more often after an androgen starts or changes",
    "HbA1c at the usual interval"
   ],
   "seekCare": [
    "Shakiness, sweating, confusion or a racing heart that improves with sugar",
    "Glucose low enough that you cannot treat it yourself (emergency services)"
   ],
   "evidence": "Moderate: drug-label precaution. The label refers to insulin; sulfonylureas are included here by assumption because they also lower glucose by raising insulin. DHEA is left out.",
   "sources": [
    {
     "citation": "Depo-Testosterone (testosterone cypionate) US prescribing information, Precautions: Drug interactions, DailyMed",
     "url": "https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=cfbb53d4-b868-4a28-8436-f9112eb01c39",
     "verifiedOn": "2026-10-04"
    }
   ],
   "management": {
    "text": "This is usually handled by the prescriber adjusting the diabetes medication; speak to them before it starts or changes.",
    "basis": "label",
    "sources": [
     {
      "citation": "Depo-Testosterone (testosterone cypionate) US prescribing information, Precautions: Drug interactions (\"Dosage of the anticoagulant may require reduction\"; \"may decrease blood glucose and, therefore, insulin requirements\"), DailyMed.",
      "url": "https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=cfbb53d4-b868-4a28-8436-f9112eb01c39",
      "verifiedOn": "2026-10-04"
     }
    ]
   }
  },
  {
   "id": "somatropin-antidiabetic",
   "tier": "interaction",
   "basis": "label",
   "audience": [
    "anabolic",
    "trt",
    "peptide"
   ],
   "match": {
    "all": [
     {
      "ids": [
       "somatropin"
      ]
     },
     {
      "ids": [
       "insulin-rapid",
       "insulin-regular",
       "insulin-glargine",
       "insulin-degludec",
       "metformin",
       "semaglutide",
       "tirzepatide",
       "liraglutide",
       "dulaglutide",
       "exenatide",
       "exenatide-extended",
       "lixisenatide",
       "albiglutide",
       "retatrutide",
       "survodutide",
       "mazdutide",
       "orforglipron",
       "amycretin"
      ],
      "tags": [
       "sulfonylurea"
      ]
     }
    ]
   },
   "title": "Growth hormone works against glucose-lowering drugs",
   "summary": "Somatropin can reduce insulin sensitivity. Its label says doses of insulin or other diabetes drugs may need adjusting when it starts.",
   "whyItMatters": "Glucose control that was stable before GH can drift once it starts.",
   "markers": [
    "Fasting glucose and HbA1c before starting and periodically on GH",
    "Home glucose readings for anyone on insulin or a sulfonylurea"
   ],
   "seekCare": [
    "Marked thirst, passing much more urine or blurred vision",
    "Signs of a low on insulin or a sulfonylurea"
   ],
   "evidence": "Strong: drug-label warning and interaction.",
   "sources": [
    {
     "citation": "Genotropin (somatropin) US prescribing information, sections 5.4 Impaired Glucose Tolerance and Diabetes Mellitus and 7.5 Insulin and/or Oral/Injectable Hypoglycemic Agents, DailyMed",
     "url": "https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=ffebf88b-d257-4542-9808-74d9b7167765",
     "verifiedOn": "2026-10-04"
    }
   ],
   "management": {
    "text": "This is usually handled by the prescriber adjusting the diabetes medication; speak to them before it starts or changes.",
    "basis": "label",
    "sources": [
     {
      "citation": "Genotropin (somatropin) US prescribing information, sections 5.4 and 7.5 (\"the dose of insulin and/or oral/injectable agent may require adjustment\"), DailyMed.",
      "url": "https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=ffebf88b-d257-4542-9808-74d9b7167765",
      "verifiedOn": "2026-10-04"
     }
    ]
   }
  },
  {
   "id": "glp1-insulin-secretagogue",
   "tier": "interaction",
   "basis": "label",
   "audience": [
    "glp1",
    "trt",
    "anabolic"
   ],
   "match": {
    "all": [
     {
      "ids": [
       "semaglutide",
       "tirzepatide",
       "liraglutide",
       "dulaglutide",
       "exenatide",
       "exenatide-extended",
       "lixisenatide",
       "albiglutide",
       "retatrutide",
       "survodutide",
       "mazdutide",
       "orforglipron",
       "amycretin"
      ]
     },
     {
      "ids": [
       "insulin-rapid",
       "insulin-regular",
       "insulin-glargine",
       "insulin-degludec"
      ],
      "tags": [
       "sulfonylurea"
      ]
     }
    ]
   },
   "title": "GLP-1 drugs with insulin or a sulfonylurea: risk of lows",
   "summary": "The semaglutide and tirzepatide labels warn of a higher risk of hypoglycemia, including severe hypoglycemia, when they are combined with insulin or a sulfonylurea.",
   "whyItMatters": "The GLP-1 adds glucose lowering on top of a regimen that was set without it.",
   "markers": [
    "Home glucose readings, especially after the GLP-1 starts",
    "HbA1c at the usual interval"
   ],
   "seekCare": [
    "Shakiness, sweating, confusion or a racing heart that improves with sugar",
    "Glucose low enough that you cannot treat it yourself (emergency services)"
   ],
   "evidence": "Strong for approved GLP-1 drugs (label interaction). For investigational incretin drugs such as retatrutide this is assumed from the shared mechanism, not shown.",
   "sources": [
    {
     "citation": "Ozempic (semaglutide injection) US prescribing information, sections 5.5 and 7.1 (insulin secretagogue or insulin), DailyMed",
     "url": "https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=42bdd912-2393-44c4-b7e0-47672ca28991",
     "verifiedOn": "2026-10-04"
    },
    {
     "citation": "Mounjaro (tirzepatide) US prescribing information, sections 7.1 and 7.2 (oral medications with a narrow therapeutic index, e.g. warfarin), DailyMed",
     "url": "https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=d2d7da5d-ad07-4228-955f-cf7e355c8cc0",
     "verifiedOn": "2026-10-04"
    }
   ],
   "management": {
    "text": "This is usually handled by the prescriber adjusting the diabetes medication; speak to them before it starts or changes.",
    "basis": "label",
    "sources": [
     {
      "citation": "Ozempic (semaglutide injection) US prescribing information, sections 5.5 and 7.1 (\"consider reducing the dose of concomitantly administered insulin secretagogue … or insulin\"), DailyMed.",
      "url": "https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=42bdd912-2393-44c4-b7e0-47672ca28991",
      "verifiedOn": "2026-10-04"
     },
     {
      "citation": "Mounjaro (tirzepatide) US prescribing information, sections 7.1 and 7.2, DailyMed.",
      "url": "https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=d2d7da5d-ad07-4228-955f-cf7e355c8cc0",
      "verifiedOn": "2026-10-04"
     }
    ]
   }
  },
  {
   "id": "glp1-warfarin",
   "tier": "interaction",
   "basis": "label",
   "audience": [
    "glp1",
    "trt"
   ],
   "match": {
    "all": [
     {
      "ids": [
       "tirzepatide"
      ]
     },
     {
      "ids": [
       "warfarin"
      ]
     }
    ]
   },
   "title": "Tirzepatide can change how oral warfarin is absorbed",
   "summary": "Tirzepatide slows stomach emptying. Its label names warfarin as an oral drug to monitor when the two are combined.",
   "whyItMatters": "Warfarin has a narrow window, so a change in absorption can move INR.",
   "markers": [
    "INR, monitored by the clinic managing warfarin while on tirzepatide"
   ],
   "seekCare": [
    "Unusual bruising or bleeding",
    "Black or bloody stools"
   ],
   "evidence": "Moderate: tirzepatide label precaution based on delayed gastric emptying; no warfarin study is cited. Semaglutide's label reports a warfarin study with no clinically relevant effect, so semaglutide is not flagged here.",
   "sources": [
    {
     "citation": "Mounjaro (tirzepatide) US prescribing information, sections 7.1 and 7.2 (oral medications with a narrow therapeutic index, e.g. warfarin), DailyMed",
     "url": "https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=d2d7da5d-ad07-4228-955f-cf7e355c8cc0",
     "verifiedOn": "2026-10-04"
    }
   ],
   "management": {
    "text": "The clinic managing warfarin usually handles this by monitoring INR more closely; tell them about the tirzepatide.",
    "basis": "label",
    "sources": [
     {
      "citation": "Mounjaro (tirzepatide) US prescribing information, sections 7.1 and 7.2, DailyMed.",
      "url": "https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=d2d7da5d-ad07-4228-955f-cf7e355c8cc0",
      "verifiedOn": "2026-10-04"
     }
    ]
   }
  },
  {
   "id": "pt141-naltrexone",
   "tier": "interaction",
   "basis": "label",
   "audience": [
    "peptide"
   ],
   "match": {
    "all": [
     {
      "ids": [
       "pt-141"
      ]
     },
     {
      "ids": [
       "naltrexone"
      ]
     }
    ]
   },
   "title": "PT-141 lowers oral naltrexone exposure",
   "summary": "The bremelanotide (Vyleesi) label says it may significantly reduce the amount of oral naltrexone absorbed and advises avoiding the pair. This applies to oral naltrexone; the label does not address low-dose naltrexone or the monthly injection.",
   "whyItMatters": "The label calls naltrexone treatment failure a severe consequence when it is treating alcohol or opioid use disorder.",
   "markers": [
    "Tell whoever prescribes the naltrexone about PT-141"
   ],
   "seekCare": [
    "Return of cravings or relapse while on naltrexone (contact the prescriber)"
   ],
   "evidence": "Strong: drug-label interaction for bremelanotide.",
   "sources": [
    {
     "citation": "Vyleesi (bremelanotide) US prescribing information, sections 5.1 Transient Increase in Blood Pressure and 7.2 Naltrexone, DailyMed",
     "url": "https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=f1d0c1b5-2f39-4bad-a6a4-0066e3ad5dcf",
     "verifiedOn": "2026-10-04"
    }
   ],
   "management": {
    "text": "The bremelanotide label advises avoiding it alongside oral naltrexone for alcohol or opioid use disorder; speak to the clinician who prescribes the naltrexone.",
    "basis": "label",
    "sources": [
     {
      "citation": "Vyleesi (bremelanotide) US prescribing information, section 7.2 Naltrexone, DailyMed.",
      "url": "https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=f1d0c1b5-2f39-4bad-a6a4-0066e3ad5dcf",
      "verifiedOn": "2026-10-04"
     }
    ]
   }
  },
  {
   "id": "aromatase-inhibitor-estrogen",
   "tier": "interaction",
   "basis": "label",
   "audience": [
    "trt",
    "anabolic"
   ],
   "match": {
    "all": [
     {
      "ids": [
       "anastrozole",
       "exemestane"
      ]
     },
     {
      "ids": [
       "estradiol",
       "estradiol-valerate",
       "estradiol-patch",
       "estradiol-other"
      ]
     }
    ]
   },
   "title": "Estrogen products blunt aromatase inhibitors",
   "summary": "The anastrozole and exemestane labels say estrogen-containing products should not be used with them because they reduce the drug's action.",
   "whyItMatters": "The estrogen product works against what the aromatase inhibitor is there to do.",
   "markers": [
    "Estradiol (sensitive assay) after any change to either"
   ],
   "seekCare": [],
   "evidence": "Strong: drug-label interaction.",
   "sources": [
    {
     "citation": "Arimidex (anastrozole) US prescribing information, section 7 Drug Interactions (7.1 Tamoxifen, 7.2 Estrogen), DailyMed",
     "url": "https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=acbfaaa9-503c-4691-9828-76a7146ed6de",
     "verifiedOn": "2026-10-04"
    },
    {
     "citation": "Aromasin (exemestane) US prescribing information, section 5.3 Administration with Estrogen-Containing Agents, DailyMed",
     "url": "https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=cf066b7a-032a-416c-8d40-15ba581423e3",
     "verifiedOn": "2026-10-04"
    }
   ],
   "management": {
    "text": "The labels advise against estrogen-containing products alongside an aromatase inhibitor; speak to the prescriber.",
    "basis": "label",
    "sources": [
     {
      "citation": "Arimidex (anastrozole) US prescribing information, sections 7.1 Tamoxifen and 7.2 Estrogen, DailyMed.",
      "url": "https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=acbfaaa9-503c-4691-9828-76a7146ed6de",
      "verifiedOn": "2026-10-04"
     },
     {
      "citation": "Aromasin (exemestane) US prescribing information, section 5.3 Administration with Estrogen-Containing Agents, DailyMed.",
      "url": "https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=cf066b7a-032a-416c-8d40-15ba581423e3",
      "verifiedOn": "2026-10-04"
     }
    ]
   }
  },
  {
   "id": "t3-sympathomimetic",
   "tier": "interaction",
   "basis": "label",
   "audience": [
    "anabolic"
   ],
   "match": {
    "all": [
     {
      "ids": [
       "liothyronine"
      ]
     },
     {
      "tags": [
       "sympathomimetic"
      ]
     }
    ]
   },
   "title": "T3 with clenbuterol or ephedrine strains the heart",
   "summary": "The liothyronine label warns that thyroid hormone used for weight loss can be life-threatening at higher doses, particularly with sympathomimetic drugs. Clenbuterol and ephedrine are sympathomimetics.",
   "whyItMatters": "Both raise heart rate and cardiac workload. The label flags the combination specifically.",
   "markers": [
    "Resting heart rate and blood pressure",
    "TSH, free T4 and free T3"
   ],
   "seekCare": [
    "Chest pain or pressure (emergency services)",
    "A racing or irregular heartbeat that does not settle",
    "Fainting or severe shortness of breath (emergency services)"
   ],
   "evidence": "Strong: boxed warning and interaction section of the liothyronine label.",
   "sources": [
    {
     "citation": "Cytomel (liothyronine) US prescribing information, boxed warning and section 7.7 Sympathomimetics, DailyMed",
     "url": "https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=51452b31-ff68-4e0c-b982-c15502ebf1d3",
     "verifiedOn": "2026-10-04"
    },
    {
     "citation": "Kumari S, et al. Adverse events of clenbuterol among athletes: a systematic review of case reports and case series. Int J Legal Med 2023;137(4):1023-1037.",
     "url": "https://pubmed.ncbi.nlm.nih.gov/37062796/",
     "verifiedOn": "2026-10-04"
    }
   ]
  },
  {
   "id": "t3-warfarin",
   "tier": "interaction",
   "basis": "label",
   "audience": [
    "anabolic"
   ],
   "match": {
    "all": [
     {
      "ids": [
       "liothyronine"
      ]
     },
     {
      "ids": [
       "warfarin"
      ]
     }
    ]
   },
   "title": "T3 strengthens warfarin",
   "summary": "The liothyronine label says it increases the response to oral anticoagulants. Whoever manages the warfarin needs to know about the T3.",
   "whyItMatters": "Starting T3 or raising it can move INR without any change to the warfarin.",
   "markers": [
    "INR, checked by the clinic managing warfarin, when T3 starts or changes"
   ],
   "seekCare": [
    "Unusual bruising or bleeding gums",
    "Black or bloody stools, or blood in urine",
    "Coughing or vomiting blood (emergency services)"
   ],
   "evidence": "Strong: drug-label interaction.",
   "sources": [
    {
     "citation": "Cytomel (liothyronine) US prescribing information, sections 7.2 Antidiabetic Therapy and 7.3 Oral Anticoagulants, DailyMed",
     "url": "https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=51452b31-ff68-4e0c-b982-c15502ebf1d3",
     "verifiedOn": "2026-10-04"
    }
   ],
   "management": {
    "text": "The clinic managing warfarin usually handles this by checking INR more closely and adjusting the anticoagulant; tell them before it starts or stops.",
    "basis": "label",
    "sources": [
     {
      "citation": "Cytomel (liothyronine) US prescribing information, sections 7.2 Antidiabetic Therapy and 7.3 Oral Anticoagulants, DailyMed.",
      "url": "https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=51452b31-ff68-4e0c-b982-c15502ebf1d3",
      "verifiedOn": "2026-10-04"
     }
    ]
   }
  },
  {
   "id": "t3-antidiabetic",
   "tier": "interaction",
   "basis": "label",
   "audience": [
    "anabolic",
    "glp1"
   ],
   "match": {
    "all": [
     {
      "ids": [
       "liothyronine"
      ]
     },
     {
      "ids": [
       "insulin-rapid",
       "insulin-regular",
       "insulin-glargine",
       "insulin-degludec",
       "metformin",
       "semaglutide",
       "tirzepatide",
       "liraglutide",
       "dulaglutide",
       "exenatide",
       "exenatide-extended",
       "lixisenatide",
       "albiglutide",
       "retatrutide",
       "survodutide",
       "mazdutide",
       "orforglipron",
       "amycretin"
      ],
      "tags": [
       "sulfonylurea"
      ]
     }
    ]
   },
   "title": "T3 can push glucose up on diabetes medication",
   "summary": "The liothyronine label says adding it may worsen glucose control and raise the need for diabetes medication or insulin.",
   "whyItMatters": "A glucose regimen set before T3 can stop holding once it starts or changes.",
   "markers": [
    "Glucose readings and HbA1c, especially when T3 is started, changed or stopped"
   ],
   "seekCare": [
    "Marked thirst, passing much more urine or blurred vision"
   ],
   "evidence": "Strong: drug-label interaction.",
   "sources": [
    {
     "citation": "Cytomel (liothyronine) US prescribing information, sections 7.2 Antidiabetic Therapy and 7.3 Oral Anticoagulants, DailyMed",
     "url": "https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=51452b31-ff68-4e0c-b982-c15502ebf1d3",
     "verifiedOn": "2026-10-04"
    }
   ],
   "management": {
    "text": "This is usually handled by the prescriber adjusting the diabetes medication; speak to them before it starts or changes.",
    "basis": "label",
    "sources": [
     {
      "citation": "Cytomel (liothyronine) US prescribing information, sections 7.2 Antidiabetic Therapy and 7.3 Oral Anticoagulants, DailyMed.",
      "url": "https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=51452b31-ff68-4e0c-b982-c15502ebf1d3",
      "verifiedOn": "2026-10-04"
     }
    ]
   }
  },
  {
   "id": "liver-17aa",
   "tier": "load",
   "basis": "clinical",
   "audience": [
    "anabolic"
   ],
   "match": {
    "all": [
     {
      "class": {
       "alkylation17a": true
      }
     }
    ]
   },
   "title": "17α-alkylated compound: liver load",
   "summary": "The modification that lets these compounds survive being swallowed also slows their clearance through the liver. Liver injury, cholestasis and lipid changes are documented with this class.",
   "whyItMatters": "Injury with this class is often cholestatic, which is why bilirubin and GGT sit on the panel alongside ALT and AST.",
   "markers": [
    "ALT, AST, GGT and bilirubin before starting and partway through",
    "Heavy weightlifting alone can raise ALT and AST for at least a week; bilirubin and GGT were not raised in the same study"
   ],
   "seekCare": [
    "Yellow skin or eyes",
    "Dark urine, pale stools or persistent itching",
    "Pain under the right ribs"
   ],
   "evidence": "Moderate: consistent case series and reviews for the class.",
   "sources": [
    {
     "citation": "Niedfeldt MW. Anabolic steroid effect on the liver. Curr Sports Med Rep 2018;17(3):97-102.",
     "url": "https://pubmed.ncbi.nlm.nih.gov/29521706/",
     "verifiedOn": "2026-10-04"
    },
    {
     "citation": "Petrovic A, et al. Anabolic androgenic steroid-induced liver injury: an update. World J Gastroenterol 2022;28(26):3071-3080.",
     "url": "https://pubmed.ncbi.nlm.nih.gov/36051334/",
     "verifiedOn": "2026-10-04"
    },
    {
     "citation": "Pettersson J, et al. Muscular exercise can cause highly pathological liver function tests in healthy men. Br J Clin Pharmacol 2008;65(2):253-259.",
     "url": "https://pubmed.ncbi.nlm.nih.gov/17764474/",
     "verifiedOn": "2026-10-04"
    },
    {
     "citation": "Depo-Testosterone (testosterone cypionate) US prescribing information, Warnings (venous thromboembolism; 17-α-alkyl-androgens and the liver), Precautions: Laboratory tests and Drug interactions, DailyMed",
     "url": "https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=cfbb53d4-b868-4a28-8436-f9112eb01c39",
     "verifiedOn": "2026-10-04"
    }
   ],
   "management": {
    "text": "Liver injury on an oral usually resolves once the compound is stopped under a clinician's care; for established injury some clinicians add ursodeoxycholic acid (UDCA), though its benefit is unproven. Speak to a clinician.",
    "basis": "clinical",
    "sources": [
     {
      "citation": "Abeles RD, et al. Androgenic anabolic steroid-induced liver injury: two case reports assessed for causality by the updated RUCAM score and a comprehensive review of the literature. BMJ Open Gastroenterol 2020;7(1):e000549 (\"Most DILIs resolve with cessation of the causative agent\"; ursodeoxycholic acid \"reasonable to consider… in symptomatic patients\"; \"proving efficacy for therapies remains challenging\").",
      "url": "https://pubmed.ncbi.nlm.nih.gov/33214235/",
      "verifiedOn": "2026-10-04"
     }
    ]
   }
  },
  {
   "id": "liver-17aa-stacked",
   "tier": "load",
   "basis": "clinical",
   "audience": [
    "anabolic"
   ],
   "match": {
    "all": [
     {
      "class": {
       "alkylation17a": true
      },
      "minCount": 2
     }
    ]
   },
   "title": "More than one 17α-alkylated oral at once",
   "summary": "Two or more 17α-alkylated compounds put their liver load on the same organ at the same time. Reviews note that running several compounds together raises the risk of adverse effects.",
   "whyItMatters": "No study measures this exact combination, so the only read on it is your own liver panel.",
   "markers": [
    "ALT, AST, GGT and bilirubin before starting and partway through"
   ],
   "seekCare": [
    "Yellow skin or eyes",
    "Dark urine, pale stools or persistent itching",
    "Pain under the right ribs"
   ],
   "evidence": "Low for the combination itself (inferred from class effects); moderate for each compound's class.",
   "sources": [
    {
     "citation": "Niedfeldt MW. Anabolic steroid effect on the liver. Curr Sports Med Rep 2018;17(3):97-102.",
     "url": "https://pubmed.ncbi.nlm.nih.gov/29521706/",
     "verifiedOn": "2026-10-04"
    },
    {
     "citation": "Petrovic A, et al. Anabolic androgenic steroid-induced liver injury: an update. World J Gastroenterol 2022;28(26):3071-3080.",
     "url": "https://pubmed.ncbi.nlm.nih.gov/36051334/",
     "verifiedOn": "2026-10-04"
    }
   ],
   "management": {
    "text": "Liver injury on these orals usually resolves once the compound is stopped under a clinician's care; for established injury some clinicians add ursodeoxycholic acid (UDCA), though its benefit is unproven. Speak to a clinician.",
    "basis": "clinical",
    "sources": [
     {
      "citation": "Abeles RD, et al. Androgenic anabolic steroid-induced liver injury: two case reports assessed for causality by the updated RUCAM score and a comprehensive review of the literature. BMJ Open Gastroenterol 2020;7(1):e000549 (\"Most DILIs resolve with cessation of the causative agent\"; ursodeoxycholic acid \"reasonable to consider… in symptomatic patients\"; \"proving efficacy for therapies remains challenging\").",
      "url": "https://pubmed.ncbi.nlm.nih.gov/33214235/",
      "verifiedOn": "2026-10-04"
     }
    ]
   }
  },
  {
   "id": "liver-oral-sarm",
   "tier": "load",
   "basis": "clinical",
   "audience": [
    "anabolic"
   ],
   "match": {
    "all": [
     {
      "class": {
       "alkylation17a": true
      }
     },
     {
      "tags": [
       "sarm"
      ]
     }
    ]
   },
   "title": "17α-alkylated oral plus a SARM",
   "summary": "SARMs have their own published cases of drug-induced liver injury. Adding one to a 17α-alkylated oral puts two liver stresses on the same organ.",
   "whyItMatters": "Two sources of liver strain make a rising liver panel harder to attribute and more likely.",
   "markers": [
    "ALT, AST, GGT and bilirubin before starting and partway through"
   ],
   "seekCare": [
    "Yellow skin or eyes",
    "Dark urine, pale stools or persistent itching",
    "Pain under the right ribs"
   ],
   "evidence": "Low for the combination (inferred); case-level for SARM liver injury.",
   "sources": [
    {
     "citation": "Barbara M, Dhingra S, Mindikoglu AL. Drug-induced liver injury associated with Alpha Bolic (RAD-140) and Alpha Elite (RAD-140 and LGD-4033). ACG Case Rep J 2020;7(6):e00409.",
     "url": "https://pubmed.ncbi.nlm.nih.gov/33062783/",
     "verifiedOn": "2026-10-04"
    },
    {
     "citation": "Nash E, et al. Drug-induced liver injury from selective androgen receptor modulators, anabolic-androgenic steroids and bodybuilding supplements in Australia. Aliment Pharmacol Ther 2024;59(8):953-961.",
     "url": "https://pubmed.ncbi.nlm.nih.gov/38372012/",
     "verifiedOn": "2026-10-04"
    },
    {
     "citation": "Niedfeldt MW. Anabolic steroid effect on the liver. Curr Sports Med Rep 2018;17(3):97-102.",
     "url": "https://pubmed.ncbi.nlm.nih.gov/29521706/",
     "verifiedOn": "2026-10-04"
    }
   ],
   "management": {
    "text": "Liver injury on an oral or a SARM usually resolves once the compound is stopped under a clinician's care; for established injury some clinicians add ursodeoxycholic acid (UDCA), though its benefit is unproven. Speak to a clinician.",
    "basis": "clinical",
    "sources": [
     {
      "citation": "Abeles RD, et al. Androgenic anabolic steroid-induced liver injury: two case reports assessed for causality by the updated RUCAM score and a comprehensive review of the literature. BMJ Open Gastroenterol 2020;7(1):e000549 (\"Most DILIs resolve with cessation of the causative agent\"; ursodeoxycholic acid \"reasonable to consider… in symptomatic patients\"; \"proving efficacy for therapies remains challenging\").",
      "url": "https://pubmed.ncbi.nlm.nih.gov/33214235/",
      "verifiedOn": "2026-10-04"
     },
     {
      "citation": "Leung K, Yaramada P, Goyal P, Cai CX. RAD-140 drug-induced liver injury. Ochsner J 2022;22(4):361-365.",
      "url": "https://pubmed.ncbi.nlm.nih.gov/36561105/",
      "verifiedOn": "2026-10-04"
     }
    ]
   }
  },
  {
   "id": "lipids-oral",
   "tier": "load",
   "basis": "clinical",
   "audience": [
    "anabolic"
   ],
   "match": {
    "all": [
     {
      "class": {
       "alkylation17a": true
      }
     }
    ]
   },
   "title": "Oral compound: HDL drops sharply",
   "summary": "In a small crossover study, oral stanozolol cut HDL cholesterol far more than injected testosterone did and raised LDL. Oral 17α-alkylated compounds as a class are known for this.",
   "whyItMatters": "A lipid shift like this adds to cardiovascular risk while it lasts.",
   "markers": [
    "Lipid panel (HDL, LDL, triglycerides; ApoB if available) before starting and partway through"
   ],
   "seekCare": [
    "Chest pain or pressure (emergency services)"
   ],
   "evidence": "Moderate: small crossover study (11 male weightlifters, 6 weeks) plus consistent class data.",
   "sources": [
    {
     "citation": "Thompson PD, et al. Contrasting effects of testosterone and stanozolol on serum lipoprotein levels. JAMA 1989;261(8):1165-1168.",
     "url": "https://pubmed.ncbi.nlm.nih.gov/2915439/",
     "verifiedOn": "2026-10-04"
    },
    {
     "citation": "Niedfeldt MW. Anabolic steroid effect on the liver. Curr Sports Med Rep 2018;17(3):97-102.",
     "url": "https://pubmed.ncbi.nlm.nih.gov/29521706/",
     "verifiedOn": "2026-10-04"
    }
   ]
  },
  {
   "id": "hematocrit",
   "tier": "load",
   "basis": "clinical",
   "audience": [
    "anabolic",
    "trt"
   ],
   "match": {
    "all": [
     {
      "class": {
       "hematocritRisk": [
        "high"
       ]
      }
     }
    ]
   },
   "title": "Red cell count tends to climb",
   "summary": "Testosterone raises hemoglobin and hematocrit in a dose-dependent way. Other androgens flagged here are assumed to do the same, a class assumption the cited studies do not test, though the testosterone label asks for periodic checks with any long-term androgen use.",
   "whyItMatters": "A high hematocrit thickens the blood, which is why guidelines set thresholds for it on testosterone.",
   "markers": [
    "CBC (hematocrit and hemoglobin) before starting and at intervals on therapy",
    "Ferritin and iron studies, if you give blood repeatedly"
   ],
   "seekCare": [
    "Severe headache, vision changes or confusion",
    "Chest pain or sudden shortness of breath (emergency services)",
    "A painful swollen leg"
   ],
   "evidence": "Strong for testosterone (dose-response study and guideline); weaker for other compounds. In one blood-service study, repeat donation did not keep hematocrit below 54% in many men on testosterone.",
   "sources": [
    {
     "citation": "Coviello AD, et al. Effects of graded doses of testosterone on erythropoiesis in healthy young and older men. J Clin Endocrinol Metab 2008;93(3):914-919.",
     "url": "https://pubmed.ncbi.nlm.nih.gov/18160461/",
     "verifiedOn": "2026-10-04"
    },
    {
     "citation": "Bhasin S, et al. Testosterone therapy in men with hypogonadism: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 2018;103(5):1715-1744.",
     "url": "https://pubmed.ncbi.nlm.nih.gov/29562364/",
     "verifiedOn": "2026-10-04"
    },
    {
     "citation": "Depo-Testosterone (testosterone cypionate) US prescribing information, Warnings (venous thromboembolism; 17-α-alkyl-androgens and the liver), Precautions: Laboratory tests and Drug interactions, DailyMed",
     "url": "https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=cfbb53d4-b868-4a28-8436-f9112eb01c39",
     "verifiedOn": "2026-10-04"
    },
    {
     "citation": "Bond P, Verdegaal T, Smit DL. Testosterone therapy-induced erythrocytosis: can phlebotomy be justified? Endocr Connect 2024;13(10):e240283 (guidelines mention therapeutic phlebotomy; evidence for it is lacking; phlebotomy \"eventually depletes iron stores\"; shared decision-making recommended).",
     "url": "https://pubmed.ncbi.nlm.nih.gov/39212549/",
     "verifiedOn": "2026-10-04"
    }
   ],
   "management": {
    "text": "A high hematocrit needs a clinician, who usually reviews the androgen first. Some doctors recommend therapeutic phlebotomy or blood donation, though evidence that it helps is limited and in one blood-service study repeat donation often did not bring hematocrit down. Repeated draws can also run iron down, so ferritin and iron levels matter.",
    "basis": "clinical",
    "sources": [
     {
      "citation": "Basheer B, Ila V, Barros R, et al. Management of adverse effects in testosterone replacement therapy. Int Braz J Urol 2025;51(3):e20259904 (narrative review: raised estrogen \"usually managed with aromatase inhibitors and tamoxifen\"; \"therapeutic phlebotomy is indicated\" for raised hematocrit).",
      "url": "https://pubmed.ncbi.nlm.nih.gov/39908204/",
      "verifiedOn": "2026-10-04"
     },
     {
      "citation": "Chin-Yee B, Lazo-Langner A, Butler-Foster T, Hsia C, Chin-Yee I. Blood donation and testosterone replacement therapy. Transfusion 2017;57(3):578-581 (the guideline threshold \"has been interpreted by some physicians and patients to indicate the need for phlebotomy or blood donation\"; repeat donation did not keep hematocrit below 54% in 44% of repeat donors).",
      "url": "https://pubmed.ncbi.nlm.nih.gov/28150363/",
      "verifiedOn": "2026-10-04"
     },
     {
      "citation": "Bond P, Verdegaal T, Smit DL. Testosterone therapy-induced erythrocytosis: can phlebotomy be justified? Endocr Connect 2024;13(10):e240283 (guidelines mention therapeutic phlebotomy; evidence for it is lacking; phlebotomy \"eventually depletes iron stores\"; shared decision-making recommended).",
      "url": "https://pubmed.ncbi.nlm.nih.gov/39212549/",
      "verifiedOn": "2026-10-04"
     }
    ]
   }
  },
  {
   "id": "hematocrit-stacked",
   "tier": "load",
   "basis": "clinical",
   "audience": [
    "anabolic"
   ],
   "match": {
    "all": [
     {
      "class": {
       "hematocritRisk": [
        "moderate",
        "high"
       ]
      },
      "minCount": 2
     }
    ]
   },
   "title": "Several compounds pushing hematocrit at once",
   "summary": "More than one compound in this stack is associated with rising red cell mass. For testosterone the effect is dose-dependent, so a second compound plausibly adds to it; that is an inference, not measured.",
   "whyItMatters": "Nothing has measured these combinations directly, so the CBC is the only read.",
   "markers": [
    "CBC (hematocrit and hemoglobin) before starting and partway through",
    "Ferritin and iron studies, if you give blood repeatedly"
   ],
   "seekCare": [
    "Severe headache, vision changes or confusion",
    "Chest pain or sudden shortness of breath (emergency services)",
    "A painful swollen leg"
   ],
   "evidence": "Low for the combination (inferred from dose-response data); strong for testosterone alone.",
   "sources": [
    {
     "citation": "Coviello AD, et al. Effects of graded doses of testosterone on erythropoiesis in healthy young and older men. J Clin Endocrinol Metab 2008;93(3):914-919.",
     "url": "https://pubmed.ncbi.nlm.nih.gov/18160461/",
     "verifiedOn": "2026-10-04"
    },
    {
     "citation": "Bhasin S, et al. Testosterone therapy in men with hypogonadism: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 2018;103(5):1715-1744.",
     "url": "https://pubmed.ncbi.nlm.nih.gov/29562364/",
     "verifiedOn": "2026-10-04"
    },
    {
     "citation": "Depo-Testosterone (testosterone cypionate) US prescribing information, Warnings (venous thromboembolism; 17-α-alkyl-androgens and the liver), Precautions: Laboratory tests and Drug interactions, DailyMed",
     "url": "https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=cfbb53d4-b868-4a28-8436-f9112eb01c39",
     "verifiedOn": "2026-10-04"
    },
    {
     "citation": "Bond P, Verdegaal T, Smit DL. Testosterone therapy-induced erythrocytosis: can phlebotomy be justified? Endocr Connect 2024;13(10):e240283 (guidelines mention therapeutic phlebotomy; evidence for it is lacking; phlebotomy \"eventually depletes iron stores\"; shared decision-making recommended).",
     "url": "https://pubmed.ncbi.nlm.nih.gov/39212549/",
     "verifiedOn": "2026-10-04"
    }
   ],
   "management": {
    "text": "A high hematocrit needs a clinician, who usually reviews the androgen first. Some doctors recommend therapeutic phlebotomy or blood donation, though evidence that it helps is limited and in one blood-service study repeat donation often did not bring hematocrit down. Repeated draws can also run iron down, so ferritin and iron levels matter.",
    "basis": "clinical",
    "sources": [
     {
      "citation": "Basheer B, Ila V, Barros R, et al. Management of adverse effects in testosterone replacement therapy. Int Braz J Urol 2025;51(3):e20259904 (narrative review: raised estrogen \"usually managed with aromatase inhibitors and tamoxifen\"; \"therapeutic phlebotomy is indicated\" for raised hematocrit).",
      "url": "https://pubmed.ncbi.nlm.nih.gov/39908204/",
      "verifiedOn": "2026-10-04"
     },
     {
      "citation": "Chin-Yee B, Lazo-Langner A, Butler-Foster T, Hsia C, Chin-Yee I. Blood donation and testosterone replacement therapy. Transfusion 2017;57(3):578-581 (the guideline threshold \"has been interpreted by some physicians and patients to indicate the need for phlebotomy or blood donation\"; repeat donation did not keep hematocrit below 54% in 44% of repeat donors).",
      "url": "https://pubmed.ncbi.nlm.nih.gov/28150363/",
      "verifiedOn": "2026-10-04"
     },
     {
      "citation": "Bond P, Verdegaal T, Smit DL. Testosterone therapy-induced erythrocytosis: can phlebotomy be justified? Endocr Connect 2024;13(10):e240283 (guidelines mention therapeutic phlebotomy; evidence for it is lacking; phlebotomy \"eventually depletes iron stores\"; shared decision-making recommended).",
      "url": "https://pubmed.ncbi.nlm.nih.gov/39212549/",
      "verifiedOn": "2026-10-04"
     }
    ]
   }
  },
  {
   "id": "prolactin-19-nor",
   "tier": "thin",
   "basis": "mechanism",
   "audience": [
    "anabolic"
   ],
   "match": {
    "all": [
     {
      "class": {
       "is19Nor": true
      },
      "tags": [
       "19-nor"
      ]
     }
    ]
   },
   "title": "19-nor compound: progestin-like structure, human effect not shown",
   "summary": "Nandrolone (19-nortestosterone) is the parent structure of prescription progestins such as norethisterone and levonorgestrel. In animal receptor studies nandrolone and trenbolone bind the progesterone receptor; whether that does anything in men has not been shown.",
   "whyItMatters": "An estradiol result does not read this receptor. We found no human study tying 19-nor use to raised prolactin, so prolactin is worth testing when symptoms appear rather than assumed.",
   "markers": [
    "Prolactin, if libido falls or the nipples change"
   ],
   "seekCare": [
    "Nipple discharge or a tender lump behind the nipple (see a doctor)"
   ],
   "evidence": "Thin: chemistry (the parent structure of progestins) and animal receptor binding only; no human study shows a prolactin effect. Trestolone and other 19-nors are assumed to share the structure-based activity.",
   "sources": [
    {
     "citation": "Reel JR, et al. Competitive progesterone antagonists: receptor binding and biologic activity of testosterone and 19-nortestosterone derivatives. Fertil Steril 1979;31(5):552-561.",
     "url": "https://pubmed.ncbi.nlm.nih.gov/446780/",
     "verifiedOn": "2026-10-04"
    },
    {
     "citation": "Schindler AE, et al. Classification and pharmacology of progestins. Maturitas 2003;46 Suppl 1:S7-S16 (19-nortestosterone derivatives include norethisterone and levonorgestrel).",
     "url": "https://pubmed.ncbi.nlm.nih.gov/14670641/",
     "verifiedOn": "2026-10-04"
    },
    {
     "citation": "Bauer ER, et al. Characterization of the affinity of different anabolics and synthetic hormones to the human androgen receptor, human sex hormone binding globulin and to the bovine progestin receptor. APMIS 2000;108(12):838-846.",
     "url": "https://pubmed.ncbi.nlm.nih.gov/11252818/",
     "verifiedOn": "2026-10-04"
    }
   ],
   "management": {
    "text": "Anabolic users also take cabergoline off-label, often to counter suspected 19-nor side effects; whether 19-nors raise prolactin in men is not established, so test prolactin first and speak to a clinician.",
    "basis": "off-label",
    "sources": [
     {
      "citation": "Bonnecaze AK, O'Connor T, Aloi JA. Characteristics and attitudes of men using anabolic androgenic steroids (AAS): a survey of 2385 men. Am J Mens Health 2020;14(6):1557988320966536 (cabergoline or bromocriptine used on cycle by 266 of 2,384 respondents, 11%).",
      "url": "https://pubmed.ncbi.nlm.nih.gov/33307930/",
      "verifiedOn": "2026-10-04"
     },
     {
      "citation": "Blazewicz A, et al. Illegal and falsified medicines self-administrated in not approved post-cycle therapy after the cessation of anabolic-androgenic steroids. Front Chem 2025;13:1536858 (seized-product analysis: of 6 samples declared as cabergoline, 2 lacked it; the authors' background section states, without a cited source, that cabergoline 'is recommended' alongside nandrolone and trenbolone in user practice).",
      "url": "https://pubmed.ncbi.nlm.nih.gov/40177353/",
      "verifiedOn": "2026-10-04"
     }
    ]
   }
  },
  {
   "id": "estradiol-none",
   "tier": "load",
   "basis": "mechanism",
   "audience": [
    "anabolic"
   ],
   "match": {
    "all": [
     {
      "class": {
       "baseClass": [
        "androgen"
       ]
      }
     },
     {
      "class": {
       "hpgSuppression": [
        "total",
        "strong"
       ]
      }
     }
    ],
    "none": [
     {
      "class": {
       "baseClass": [
        "androgen"
       ],
       "aromatization": [
        "mild",
        "moderate",
        "heavy"
       ]
      }
     },
     {
      "ids": [
       "estradiol",
       "estradiol-valerate",
       "estradiol-patch",
       "estradiol-other"
      ]
     }
    ]
   },
   "title": "Nothing here converts to estradiol",
   "summary": "No androgen in this stack aromatizes, while the stack suppresses your own production. Estradiol can end up low with nothing replacing it.",
   "whyItMatters": "In a controlled study of men, estrogen deficiency mainly raised body fat and added to a decline in sexual function.",
   "markers": [
    "Estradiol (sensitive assay) partway through"
   ],
   "seekCare": [],
   "evidence": "Low: inferred from each compound's pharmacology; no study of these stacks.",
   "sources": [
    {
     "citation": "Finkelstein JS, et al. Gonadal steroids and body composition, strength, and sexual function in men. N Engl J Med 2013;369(11):1011-1022.",
     "url": "https://pubmed.ncbi.nlm.nih.gov/24024838/",
     "verifiedOn": "2026-10-04"
    }
   ]
  },
  {
   "id": "estradiol-weak",
   "tier": "load",
   "basis": "mechanism",
   "audience": [
    "anabolic"
   ],
   "match": {
    "all": [
     {
      "class": {
       "baseClass": [
        "androgen"
       ],
       "aromatization": [
        "mild"
       ]
      }
     },
     {
      "class": {
       "hpgSuppression": [
        "total",
        "strong"
       ]
      }
     }
    ],
    "none": [
     {
      "class": {
       "baseClass": [
        "androgen"
       ],
       "aromatization": [
        "moderate",
        "heavy"
       ]
      }
     }
    ]
   },
   "title": "Converts to estradiol, but weakly",
   "summary": "What aromatizes here is thought to do so less than testosterone does. If the stack also suppresses your own production, estradiol can end up lower than the stack suggests.",
   "whyItMatters": "A stack that reads as aromatizing can still leave estradiol low. In a controlled study of men, estrogen deficiency mainly raised body fat.",
   "markers": [
    "Estradiol (sensitive assay) partway through"
   ],
   "seekCare": [],
   "evidence": "Low: inferred from each compound's pharmacology; no study of these stacks.",
   "sources": [
    {
     "citation": "Finkelstein JS, et al. Gonadal steroids and body composition, strength, and sexual function in men. N Engl J Med 2013;369(11):1011-1022.",
     "url": "https://pubmed.ncbi.nlm.nih.gov/24024838/",
     "verifiedOn": "2026-10-04"
    }
   ]
  },
  {
   "id": "estradiol-full",
   "tier": "load",
   "basis": "clinical",
   "audience": [
    "anabolic",
    "trt"
   ],
   "match": {
    "all": [
     {
      "class": {
       "baseClass": [
        "androgen"
       ],
       "aromatization": [
        "moderate",
        "heavy"
       ]
      }
     }
    ]
   },
   "title": "Converts to estradiol",
   "summary": "Part of this stack aromatizes, so estradiol tends to rise with the androgen load.",
   "whyItMatters": "Estradiol that is too high and estradiol that is too low both cause symptoms. Only a blood test tells them apart.",
   "markers": [
    "Estradiol (sensitive assay) if symptoms suggest it is high or low"
   ],
   "seekCare": [],
   "evidence": "Follows from pharmacology: testosterone is converted to estradiol. The cited guideline does not set routine estradiol monitoring.",
   "sources": [
    {
     "citation": "Finkelstein JS, et al. Gonadal steroids and body composition, strength, and sexual function in men. N Engl J Med 2013;369(11):1011-1022.",
     "url": "https://pubmed.ncbi.nlm.nih.gov/24024838/",
     "verifiedOn": "2026-10-04"
    },
    {
     "citation": "Bhasin S, et al. Testosterone therapy in men with hypogonadism: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 2018;103(5):1715-1744.",
     "url": "https://pubmed.ncbi.nlm.nih.gov/29562364/",
     "verifiedOn": "2026-10-04"
    }
   ],
   "management": {
    "text": "Raised estradiol with symptoms such as breast tenderness is assessed by a clinician; an aromatase inhibitor such as anastrozole is one option they may use. It can push estradiol too low, so speak to a clinician.",
    "basis": "clinical",
    "sources": [
     {
      "citation": "Basheer B, Ila V, Barros R, et al. Management of adverse effects in testosterone replacement therapy. Int Braz J Urol 2025;51(3):e20259904 (narrative review: raised estrogen \"usually managed with aromatase inhibitors and tamoxifen\"; \"therapeutic phlebotomy is indicated\" for raised hematocrit).",
      "url": "https://pubmed.ncbi.nlm.nih.gov/39908204/",
      "verifiedOn": "2026-10-04"
     },
     {
      "citation": "Finkelstein JS, et al. Gonadal steroids and body composition, strength, and sexual function in men. N Engl J Med 2013;369(11):1011-1022 (anastrozole used \"to suppress the conversion of testosterone to estradiol\"; estrogen deficiency raised body fat and lowered sexual function).",
      "url": "https://pubmed.ncbi.nlm.nih.gov/24024838/",
      "verifiedOn": "2026-10-04"
     }
    ]
   }
  },
  {
   "id": "suppression",
   "tier": "load",
   "basis": "clinical",
   "audience": [
    "anabolic"
   ],
   "match": {
    "all": [
     {
      "class": {
       "hpgSuppression": [
        "total",
        "strong"
       ]
      }
     }
    ]
   },
   "title": "Own production shut down",
   "summary": "This stack suppresses your own testosterone production while it runs. Recovery after stopping usually takes 6–18 months; in one study some former long-term users still had low testosterone up to two years later.",
   "whyItMatters": "In one study of former users, 29% had a major depressive episode during withdrawal.",
   "markers": [
    "LH, FSH and total testosterone before starting and again after stopping"
   ],
   "seekCare": [
    "Low mood, low libido or erectile problems that persist months after stopping (see a doctor)"
   ],
   "evidence": "Moderate: observational studies of former users.",
   "sources": [
    {
     "citation": "Kanayama G, et al. Prolonged hypogonadism in males following withdrawal from anabolic-androgenic steroids: an under-recognized problem. Addiction 2015;110(5):823-831.",
     "url": "https://pubmed.ncbi.nlm.nih.gov/25598171/",
     "verifiedOn": "2026-10-04"
    },
    {
     "citation": "Shankara-Narayana N, et al. Rate and extent of recovery from reproductive and cardiac dysfunction due to androgen abuse in men. J Clin Endocrinol Metab 2020;105(6):dgz324.",
     "url": "https://pubmed.ncbi.nlm.nih.gov/32030409/",
     "verifiedOn": "2026-10-04"
    }
   ],
   "management": {
    "text": "Low testosterone after stopping is usually managed under a clinician with a SERM such as clomiphene, hCG or testosterone therapy depending on the case; speak to a clinician.",
    "basis": "clinical",
    "sources": [
     {
      "citation": "Rahnema CD, Lipshultz LI, Crosnoe LE, Kovac JR, Kim ED. Anabolic steroid-induced hypogonadism: diagnosis and treatment. Fertil Steril 2014;101(5):1271-1279 (management \"include[s] judicious use of testosterone replacement therapy, hCG, and selective estrogen receptor modulators\").",
      "url": "https://pubmed.ncbi.nlm.nih.gov/24636400/",
      "verifiedOn": "2026-10-04"
     }
    ]
   }
  },
  {
   "id": "sympathomimetic-stacked",
   "tier": "load",
   "basis": "clinical",
   "audience": [
    "anabolic"
   ],
   "match": {
    "all": [
     {
      "tags": [
       "sympathomimetic"
      ],
      "minCount": 2
     }
    ]
   },
   "title": "Clenbuterol and ephedrine together",
   "summary": "Both are sympathomimetics that raise heart rate. Clenbuterol has case reports of heart attacks and arrhythmias in athletes; a meta-analysis links ephedra with caffeine to psychiatric, stomach and heart-palpitation side effects.",
   "whyItMatters": "Their cardiac effects point the same way. No study has measured them together.",
   "markers": [
    "Resting heart rate and blood pressure"
   ],
   "seekCare": [
    "Chest pain or pressure (emergency services)",
    "A racing or irregular heartbeat that does not settle",
    "Fainting or severe shortness of breath (emergency services)"
   ],
   "evidence": "Low for the combination (case-level and inferred); case series for clenbuterol and meta-analysis for ephedra.",
   "sources": [
    {
     "citation": "Kumari S, et al. Adverse events of clenbuterol among athletes: a systematic review of case reports and case series. Int J Legal Med 2023;137(4):1023-1037.",
     "url": "https://pubmed.ncbi.nlm.nih.gov/37062796/",
     "verifiedOn": "2026-10-04"
    },
    {
     "citation": "Aggarwal A, et al. Clenbuterol-induced myocardial infarction in a young bodybuilder. BMJ Case Rep 2025;18(3):e264898.",
     "url": "https://pubmed.ncbi.nlm.nih.gov/40032559/",
     "verifiedOn": "2026-10-04"
    },
    {
     "citation": "Shekelle PG, et al. Efficacy and safety of ephedra and ephedrine for weight loss and athletic performance: a meta-analysis. JAMA 2003;289(12):1537-1545.",
     "url": "https://pubmed.ncbi.nlm.nih.gov/12672771/",
     "verifiedOn": "2026-10-04"
    }
   ]
  },
  {
   "id": "mk677-glucose",
   "tier": "load",
   "basis": "clinical",
   "audience": [
    "peptide",
    "anabolic",
    "glp1"
   ],
   "match": {
    "all": [
     {
      "ids": [
       "mk-677-ibutamoren"
      ]
     },
     {
      "ids": [
       "insulin-rapid",
       "insulin-regular",
       "insulin-glargine",
       "insulin-degludec",
       "metformin",
       "semaglutide",
       "tirzepatide",
       "liraglutide",
       "dulaglutide",
       "exenatide",
       "exenatide-extended",
       "lixisenatide",
       "albiglutide",
       "retatrutide",
       "survodutide",
       "mazdutide",
       "orforglipron",
       "amycretin"
      ],
      "tags": [
       "sulfonylurea"
      ]
     }
    ]
   },
   "title": "MK-677 raises glucose against a glucose-lowering drug",
   "summary": "In a randomized trial in older adults, MK-677 raised fasting glucose and lowered insulin sensitivity. Alongside a drug meant to lower glucose, the two pull in opposite directions.",
   "whyItMatters": "A glucose regimen set without MK-677 can stop holding once it starts.",
   "markers": [
    "Fasting glucose and HbA1c before starting and periodically"
   ],
   "seekCare": [
    "Marked thirst, passing much more urine or blurred vision"
   ],
   "evidence": "Moderate for MK-677 raising glucose (randomized trial); the combination is inferred.",
   "sources": [
    {
     "citation": "Nass R, et al. Effects of an oral ghrelin mimetic on body composition and clinical outcomes in healthy older adults: a randomized trial. Ann Intern Med 2008;149(9):601-611.",
     "url": "https://pubmed.ncbi.nlm.nih.gov/18981485/",
     "verifiedOn": "2026-10-04"
    }
   ]
  },
  {
   "id": "5ar-inhibitor-nandrolone",
   "tier": "thin",
   "basis": "mechanism",
   "audience": [
    "anabolic",
    "trt"
   ],
   "match": {
    "all": [
     {
      "tags": [
       "5ar-inhibitor"
      ]
     },
     {
      "ids": [
       "deca"
      ],
      "tags": [
       "nandrolone"
      ]
     }
    ]
   },
   "title": "Finasteride or dutasteride with nandrolone",
   "summary": "5α-reductase turns nandrolone into a weaker androgen in some tissues, so blocking the enzyme may leave nandrolone's androgenic effect stronger there. That rests on receptor-binding work in rat tissue; we found no human study of the combination.",
   "whyItMatters": "It runs opposite to how these drugs behave with testosterone, which is why the question comes up.",
   "markers": [],
   "seekCare": [],
   "evidence": "Thin: mechanism from in vitro animal receptor data only; no human outcome data.",
   "sources": [
    {
     "citation": "Toth M, Zakar T. Relative binding affinities of testosterone, 19-nortestosterone and their 5 alpha-reduced derivatives to the androgen receptor and to other androgen-binding proteins. J Steroid Biochem 1982;17(6):653-660.",
     "url": "https://pubmed.ncbi.nlm.nih.gov/6891012/",
     "verifiedOn": "2026-10-04"
    }
   ]
  },
  {
   "id": "pt141-melanotan",
   "tier": "thin",
   "basis": "mechanism",
   "audience": [
    "peptide"
   ],
   "match": {
    "all": [
     {
      "ids": [
       "pt-141"
      ]
     },
     {
      "ids": [
       "melanotan"
      ]
     }
    ]
   },
   "title": "PT-141 with melanotan",
   "summary": "Bremelanotide (PT-141) raises blood pressure for several hours after each dose, per its label. Melanotan II is thought to act on overlapping melanocortin receptors, so the two may add together, but no study has tested the pair.",
   "whyItMatters": "The blood-pressure effect is known for one of the two; the combination is an inference.",
   "markers": [
    "Blood pressure, especially in the hours after a dose"
   ],
   "seekCare": [
    "Severe headache, chest pain or vision changes (emergency services)"
   ],
   "evidence": "Thin: label data for PT-141 only; the additive effect is inferred.",
   "sources": [
    {
     "citation": "Vyleesi (bremelanotide) US prescribing information, sections 5.1 Transient Increase in Blood Pressure and 7.2 Naltrexone, DailyMed",
     "url": "https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=f1d0c1b5-2f39-4bad-a6a4-0066e3ad5dcf",
     "verifiedOn": "2026-10-04"
    },
    {
     "citation": "FDA. Certain bulk drug substances for use in compounding that may present significant safety risks (content current as of 04/22/2026)",
     "url": "https://www.fda.gov/drugs/human-drug-compounding/certain-bulk-drug-substances-use-compounding-may-present-significant-safety-risks",
     "verifiedOn": "2026-10-04"
    }
   ]
  },
  {
   "id": "peptide-no-human-data",
   "tier": "thin",
   "basis": "clinical",
   "audience": [
    "peptide"
   ],
   "match": {
    "all": [
     {
      "ids": [
       "bpc-157",
       "tb-500",
       "wolverine",
       "ipamorelin",
       "cjc-1295-no-dac",
       "cjc-1295-dac",
       "ipa-cjc",
       "ghk-cu",
       "kpv",
       "mots-c",
       "epitalon",
       "ghrp-2",
       "ghrp-6",
       "hexarelin",
       "aod-9604",
       "thymosin-alpha-1",
       "selank",
       "semax",
       "dsip"
      ],
      "minCount": 2
     }
    ]
   },
   "title": "No human interaction data for this peptide combination",
   "summary": "We found no human study of how these peptides behave together. FDA's compounding-risk list notes immunogenicity risk and little or no human safety data for many of them, with serious adverse events reported for some (CJC-1295, GHRP-2 and intravenous ipamorelin).",
   "whyItMatters": "No flag here is not the same as no risk; it means nothing has been measured.",
   "markers": [],
   "seekCare": [
    "Redness, heat or swelling spreading from an injection site, or a fever (same-day care)",
    "Face or throat swelling or trouble breathing (emergency services)"
   ],
   "evidence": "Thin: absence of human data, stated plainly.",
   "sources": [
    {
     "citation": "FDA. Certain bulk drug substances for use in compounding that may present significant safety risks (content current as of 04/22/2026)",
     "url": "https://www.fda.gov/drugs/human-drug-compounding/certain-bulk-drug-substances-use-compounding-may-present-significant-safety-risks",
     "verifiedOn": "2026-10-04"
    }
   ]
  }
 ]
}