Cushing's syndrome with adrenal suppression induced by inhaled budesonide due to a ritonavir drug interaction in a woman with HIV infection

Yoganathan, Kathir; David, Laurent; Williams, Clare; Jones, K

doi:10.1258/ijsa.2011.011408

Cited by 26 publications

(17 citation statements)

References 8 publications

(7 reference statements)

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“…62–67 Most case reports describe interactions between fluticasone and protease inhibitors, but the clinician should be aware that other inhaled corticosteroids including budesonide and, to a lesser extent, beclomethasone, can lead to hypercortisolism symptoms if they are given concomitantly with protease inhibitors. 68–70 The 2013 update of the antiretroviral treatment guidelines 71 advised clinicians to avoid co-administration of ritonavir-based ART with inhaled budesonide or fluticasone, unless the benefits clearly outweighed the risks; however, inhaled beclomethasone was not included in this advice. The adverse side-effects of inhaled budesonide or fluticasone combined with ART seem reversible with cessation of the inhaled corticosteroid.…”

Section: Pharmacotherapy Recommendations For Hiv-infected Patients Wimentioning

confidence: 99%

HIV-associated obstructive lung diseases: insights and implications for the clinician

Drummond¹,

Kirk²

2014

The Lancet Respiratory Medicine

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The effectiveness of antiretroviral therapy to control HIV infection has led to the emergence of an older HIV population who are at risk of chronic diseases. Through a comprehensive search of major databases, this Review summarises information about the associations between chronic obstructive pulmonary disease (COPD), asthma, and HIV infection. Asthma and COPD are more prevalent in HIV-infected populations; 16–20% of individuals with HIV infection have asthma or COPD, and poorly controlled HIV infection worsens spirometric and diffusing capacity measurements, and accelerates lung function decline by about 55–75 mL/year. Up to 21% of HIV-infected individuals have obstructive ventilatory defects and reduced diffusing capacity is seen in more than 50% of HIV-infected populations. Specific pharmacotherapy considerations are needed to care for HIV-infected populations with asthma or COPD–protease inhibitor regimens to treat HIV (such as ritonavir) can result in systemic accumulation of inhaled corticosteroids and might increase pneumonia risk, exacerbating the toxicity of this therapy. Therefore, it is essential for clinicians to have a heightened awareness of the increased risk and manifestations of obstructive lung diseases in HIV-infected patients and specific therapeutic considerations to care for this population. Screening spirometry and tests of diffusing capacity might be beneficial in HIV-infected people with a history of smoking or respiratory symptoms.

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Section: Pharmacotherapy Recommendations For Hiv-infected Patients Wimentioning

confidence: 99%

HIV-associated obstructive lung diseases: insights and implications for the clinician

Drummond¹,

Kirk²

2014

The Lancet Respiratory Medicine

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“…By searching PubMed and the references of pertinent articles, and by contacting relevant drug companies, we identified 51 case reports published in English regarding adverse effects with the use of inhaled ( n = 45), intranasal ( n = 2), and combination inhaled and intranasal ( n = 4) corticosteroids and PIs (Table ) . Papers were published between the years 1999 and 2012.…”

Section: Case Reports On Corticosteroid−protease Inhibitor Drug−drug mentioning

confidence: 99%

“…There were nine (18%) reported cases in the paediatric population (i.e. patients < 12 years of age) and 19 (37%) cases in women , and the mean age of patients was 36 years (range 1.8−66 years). Ritonavir was part of the antiretroviral regimen in 48 (94%) of the cases and other PIs (indinavir, saquinavir and nelfinavir) in two (4%) of cases , and the antiretroviral regimen was not reported in one case (2%) .…”

Section: Case Reports On Corticosteroid−protease Inhibitor Drug−drug mentioning

confidence: 99%

Inhaled corticosteroid use in HIV‐positive individuals taking protease inhibitors: a review of pharmacokinetics, case reports and clinical management

2013

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Due to the inhibition of hepatic cytochrome P450 3A4 isozyme, HIV protease inhibitors can result in significant drug-drug interactions. One noteworthy interaction is between protease inhibitors and inhaled or intranasal corticosteroids. This interaction can result in adrenal insufficiency, iatrogenic Cushing’s syndrome (with symptoms such as rapid weight gain, obesity, facial hirsutism and swelling, etc.), as well as hypertension, osteoporosis, and decreased CD4+ cell count. In this paper, we review and unite pharmacokinetic data, case reports, and current research regarding this drug-drug interaction in order to provide options for the clinical management of HIV-positive patients requiring treatment with protease inhibitors and inhaled or intranasal corticosteroids.

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“…The use of systemic, intranasal, or inhaled budesonide in combination with PIs is not recommended unless the potential benefits outweigh the risks, because this combination may result in decreased levels of PIs and an increase in glucocorticoids that can result in Cushing’s syndrome 106,107. Similarly, inhaled or intranasal fluticasone or systemic prednisone in combination with any boosted PI should be avoided, because it can result in adrenal insufficiency and Cushing’s syndrome 108.…”

Section: Consequences Of Polypharmacy In Older Hiv-infected Patientsmentioning

confidence: 99%

Polypharmacy in the HIV-infected older adult population

Gleason¹,

Luque²,

Shah³

2013

CIA

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The prevalence of human immunodeficiency virus (HIV) infection among people older than 50 years is increasing. Older HIV-infected patients are particularly at risk for polypharmacy because they often have multiple comorbidities that require pharmacotherapy. Overall, there is not much known with respect to both the impact of aging on medication use in HIV-infected individuals, and the potential for interactions with highly active antiretroviral therapy (HAART) and coadministered medications and its clinical consequences. In this review, we aim to provide an overview of polypharmacy with a focus on its impact on the HIV-infected older adult population and to also provide some clinical considerations in this high-risk population.

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Cushing's syndrome with adrenal suppression induced by inhaled budesonide due to a ritonavir drug interaction in a woman with HIV infection

Cited by 26 publications

References 8 publications

HIV-associated obstructive lung diseases: insights and implications for the clinician

HIV-associated obstructive lung diseases: insights and implications for the clinician

Inhaled corticosteroid use in HIV‐positive individuals taking protease inhibitors: a review of pharmacokinetics, case reports and clinical management

Polypharmacy in the HIV-infected older adult population

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