• Improvement by 10 % in Hand Grip strength in both groups [ Time Frame: 24 weeks ]
• Improvement by 10 % in6 minute walk distance in both groups [ Time Frame: 24 weeks ]
• Improvement by 10 % in the increased bone and muscle mass in both groups [ Time Frame: 24 weeks ]
• Improvement by 10 % L3 Skeletal Muscle Index in both groups. [ Time Frame: 24 weeks ]
• Improvement by 10 % in serum ammonia levels in both groups [ Time Frame: 24 weeks ]
• Improvement by 10 % in muscle fibres on Biopsy in both groups • [ Time Frame: 24 weeks ]
• Reduction in Myostatin level in both groups [ Time Frame: 24 weeks ]
• Improvement in MELD scores in both groups [ Time Frame: 24 weeks ]
• Decrease in mortality over 6 months in both groups [ Time Frame: 24 weeks ]
• Changes in HBA1C level in both groups [ Time Frame: 24 weeks ]
• Reduction in requirement of hospital admissions in both groups [ Time Frame: 24 weeks ]
• Decrease in TNF alpha levels in both groups [ Time Frame: 24 weeks ]

• Study Population- Patient with cirrhosis with any aetiology with sarcopenia visiting ILBS OPD/IPDs who are willing to visit ILBS gymnasium twice weekly for first month.
• Study Design- A Prospective Randomized Controlled Trial

• Study Period- Study will be conducted at ILBS from April 2019 to Oct 2019

  • Sample Size:As shown by Eva Roman et al - in cirhotics with sarcopenia exercise increases mean lean appendicular mass , by 0.38 kg (14 patients, p < 0.03), and Sinclair et al has shown testosterone (22 patients, p <0.05)) to increase mean Appendicular lean mass by +1.69 kg - for 10% increase in APLM
  • we need to enroll 40 patients in each arm, and considering a los to follow up approx.10% , will require minimum 44 patients in each arm
  • We will therefore enroll and randomize 100 patients with 50 in each arm.

Intervention - Testosterone Supplementation - Intramuscular Testosterone Undecanoate 1000 Mg (4 ml volume in oily base) will be injected into the upper, outer quadrant of the buttock at 0, 6, 12,16,20, 24 weeks according to manufacturer recommendations.

Monitoring and assessment - On every visit patient will be inquired or evaluated for side effects like local site pain or hematoma , hypertension, headache, allergic reactions, acne, nausea , mood swings, pedal edema , breast enlargement and others.

• Drug: Testosterone Supplementation
  Intramuscular Testosterone Undecanoate 1000 Mg (4 ml volume in oily base) will be injected into the upper, outer quadrant of the buttock at 0, 6, 12,16,20, 24 weeks according to manufacturer recommendations
• Drug: Standard Medical Treatment
  Standard Medical Treatment
• Other: Exercise
  Exercise

• Experimental: Standard Medical Treatment +Intramuscular Testosterone + Exerc
  Intramuscular Testosterone Undecanoate 1000 Mg (4 ml volume in oily base) will be injected into the upper, outer quadrant of the buttock at 0, 6, 12,16,20, 24 weeks according to manufacturer recommendations
  Interventions:

  • Drug: Testosterone Supplementation
  • Drug: Standard Medical Treatment
  • Other: Exercise
• Active Comparator: Standard Medical Treatment+Exercise
  Standard Medical Treatment +Exercise
  Interventions:

  • Drug: Standard Medical Treatment
  • Other: Exercise

Inclusion Criteria:

• Men with cirrhosis of any etiology
• Sarcopenia
• CTP 6-12

Exclusion Criteria:

• Hepatocellular carcinoma
• Other known malignancy,
• CTP > 12
• Acute liver injury
• Prostate disease,
• Known hypersensitivity to testosterone therapy,
• Polycythaemia (haematocrit >55%),
• Uncontrolled hypertension (>160/90 mmHg despite treatment),
• Uncontrolled obstructive sleep apnoea,
• Severe renal dysfunction (estimated glomerular filtration rate <30ml/min)
• Uncontrolled epilepsy, migraine, or significant cardiac insufficiency (New York Heart Association class III or IV or LVEF < 45-50%.
• CKD (Chronic Kidney Disease) - eGFR (Glomerular Filtration Rate) <60%
• Platelet count below 30,000 or taking warfarin
• Failure to give consent.