Cushing's syndrome without excess cortisol

Woods, David R.; Arun, Chankramath S; Corris, Paul; Perros, Petros

doi:10.1136/bmj.332.7539.469

Cited by 20 publications

(15 citation statements)

References 19 publications

(20 reference statements)

Supporting

Mentioning

Contrasting

Order By: Relevance

“…Itraconazole inhibits CYP3A4 (Cytochrome P450 3A4) and inhibits the clearance of synthetic glucocorticoids potentially leading to rapid development of Cushing’s syndrome (19). Diltiazem is another CYP3A4 inhibitor that has been shown to increase methylprednisolone concentrations 2.6 fold (20) and this combination should be avoided.…”

Section: Pharmacokinetics and Modes Of Administrationmentioning

confidence: 99%

The Risk Benefit Ratio of Glucocorticoids in SLE: Have Things Changed over the Past 40 years?

Stojan

Petri

2017

Curr Treat Options in Rheum

View full text Add to dashboard Cite

Purpose of review Glucocorticoids have been the mainstay of treatment in systemic lupus erythematosus for more than half a century. Despite advancements in knowledge concerning the pathophysiology of systemic lupus, the genomic/non-genomic actions of glucocorticoids, and the use of novel therapeutic agents in SLE, the burden of toxicity from glucocorticoid use remains unchanged. Recent findings SLE patients receiving long-term prednisone therapy are at significant risk of morbidity due to permanent organ damage and prednisone daily dosages above 6 mg have been shown to increase the risk of future organ damage by 50%. Glucocorticoid use carries a higher risk of opportunistic infections, iatrogenic osteoporosis and avascular necrosis, an increase in risk of cardiovascular events, cataracts and glaucoma, as well as psychiatric adverse effects like psychosis and manic episodes. There are limited data regarding the relative efficacy of the different glucocorticoid formulations or dosing regimens. Summary The use and dosing of glucocorticoids in SLE remains more art than science, although our knowledge regarding their complex genomic and non-genomic effects, as well as the resultant adverse effects, has greatly expanded over the past half a century.

show abstract

Section: Pharmacokinetics and Modes Of Administrationmentioning

confidence: 99%

The Risk Benefit Ratio of Glucocorticoids in SLE: Have Things Changed over the Past 40 years?

Stojan

Petri

2017

Curr Treat Options in Rheum

View full text Add to dashboard Cite

show abstract

“…On the basis of these observational data, it appears that inhaled beclomethasone and budesonide are less likely to be associated with a clinically significant drug interaction with ritonavir than fluticasone. However, there have been case reports of iatrogenic adrenal suppression with Cushing's syndrome when ICSs such as budesonide or fluticasone have been combined with other potent CYP3A4 inhibitors such as itraconazole [30][31][32][33][34] and even clarithromycin [34]. Caution is still warranted when any ICS is combined with ritonavir and the lowest effective dose should be used.…”

Section: Pharmacokinetics Of Icssmentioning

confidence: 99%

Adrenal suppression and Cushing's syndrome secondary to an interaction between ritonavir and fluticasone: a review of the literature

et al. 2008

View full text Add to dashboard Cite

ObjectiveThe purpose of this article is to provide a systematic overview of the literature on adrenal suppression and Cushing's syndrome secondary to an interaction between inhaled/intranasal fluticasone and ritonavir. The clinical presentation, diagnosis and management will be discussed. MethodsA literature search using Medline and EMBASE and a search of abstracts of the three previous years of major HIV-related conferences were carried out. ResultsThere were 25 cases (15 adult and 10 paediatric) of significant adrenal suppression secondary to an interaction between ritonavir and inhaled fluticasone, and three cases involving ritonavir and intranasal fluticasone. Cases with other steroids were not reported; however, there were cases of adrenal suppression with itraconazole [also a potent cytochrome p (CYP) 3A4 inhibitor] and inhaled budesonide. Clinicians need to differentiate between antiretroviral-induced lipodystrophy syndrome and iatrogenic Cushing's syndrome secondary to glucocorticoid use. Long-term fluticasone and ritonavir should be avoided. If ritonavir is required, another inhaled steroid such as low-dose budesonide or beclomethasone can be used cautiously. Upon discontinuation of inhaled corticosteroids, close monitoring for symptoms of adrenal insufficiency is warranted. The need for steroid replacement therapy at physiological doses should be assessed. ConclusionsThe combination of ritonavir and fluticasone should be avoided. Budesonide, beclomethasone, triamcinolone and flunisolide appear to be safer options.

show abstract

“…There are case reports suggesting that concomitant administration of these medications can cause Cushing's syndrome. 6 Clinicians should be aware that patients can appear clinically Cushingoid but actually they have adrenal insufficiency.…”

Section: Discussionmentioning

confidence: 99%