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Kant R, Cromer MD, Chandra R, Munir K, Verma V. Avascular Necrosis of Both Hips From Iatrogenic Cushing 's Syndrome due to Coadministration of Fluticasone and Ritonavir in an HIV-Infected Patient. Cureus 2020; 12:e9644. [PMID: 32923244 PMCID: PMC7480892 DOI: 10.7759/cureus.9644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
We report a case of avascular necrosis (AVN), hypercalcemia, and iatrogenic Cushing’s syndrome in an HIV-positive patient taking inhaled (ICS) and nasal corticosteroids fluticasone and ritonavir. A 45-year-old HIV-infected African-American woman was seen for initial evaluation for multinodular goiter in December 2015. Relevant medications were ritonavir, raltegravir, darunavir, fluticasone propionate HFA, and nasal fluticasone propionate. Physical examination revealed classical cushingoid appearance but laboratory testing showed abnormal adrenocorticotropic hormone (ACTH) stimulation test. A diagnosis of iatrogenic Cushing’s syndrome due to inhibition of fluticasone metabolism from protease inhibitor (PI) therapy with secondary adrenal suppression was made. Fluticasone nasal spray and HFA were discontinued and hydrocortisone replacement dose was initiated. The patient’s Cushing’s related symptoms improved over several months. Follow-up evaluation showed non-parathyroid hormone-mediated hypercalcemia. A detailed laboratory evaluation looking for the etiology for hypercalcemia was unremarkable except for an elevated urine N-telopeptide/creatinine ratio. Meanwhile, the patient developed a new symptom of hip pain. MRI of both hips showed bilateral AVN. Sickle cell screen was negative and a right hip replacement was completed in May 2017. Since this is the fourth case report of AVN from iatrogenic Cushing’s syndrome in an HIV-infected patient taking a PI and ICS concomitantly, there is more likely a causal relationship and not simply a coincidental finding. Extreme caution should be used when considering any ICS therapy in combination with PIs in HIV-infected patients.
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Affiliation(s)
- Ravi Kant
- Endocrinology, Diabetes and Metabolism, Medical University of South Carolina, Anderson, USA
| | - Mark D Cromer
- Internal Medicine, University of Alabama at Birmingham, Birmingham, USA
| | - Rashmi Chandra
- Internal Medicine, Medical University of South Carolina, Anderson, USA
| | - Kashif Munir
- Endocrinology, Diabetes and Metabolism, University of Maryland Medical Center, Baltimore, USA
| | - Vipin Verma
- Geriatrics, Medical University of South Carolina, Anderson, USA
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2
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Figueiredo J, Serrado M, Khmelinskii N, do Vale S. Iatrogenic Cushing syndrome and multifocal osteonecrosis caused by the interaction between inhaled fluticasone and ritonavir. BMJ Case Rep 2020; 13:13/5/e233712. [PMID: 32467117 PMCID: PMC7259854 DOI: 10.1136/bcr-2019-233712] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Inhaled corticosteroids are generally considered safe and do not usually lead to systemic adverse events since their plasma concentrations are low due to hepatic metabolism by the cytochrome P450 3A4. However, when associated with inhibitors of this cytochrome, such as ritonavir, they may lead to iatrogenic Cushing syndrome by the systemic accumulation of corticosteroids and consequent suppression of the hypothalamic-pituitary-adrenal axis. We present a case of iatrogenic Cushing syndrome complicated by multifocal osteonecrosis in a patient with HIV infection on antiretroviral therapy with protease inhibitors boosted with ritonavir, after the association of inhaled fluticasone. This clinical case highlights a relevant interaction between corticosteroids and inhibitors of the cytochrome P450 and the severe consequences that may occur.
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Affiliation(s)
- Joana Figueiredo
- Serviço de Endocrinologia, Universidade de Lisboa Faculdade de Medicina, Lisboa, Portugal
| | - Margarida Serrado
- Hospital de Santa Maria, Serviço de Doenças Infecciosas, Centro Hospitalar Lisboa Norte EPE, Lisboa, Portugal
| | - Nikita Khmelinskii
- Hospital de Santa Maria, Serviço de Reumatologia e Doenças Ósseas Metabólicas, Centro Hospitalar Lisboa Norte EPE, Lisboa, Portugal.,Unidade de Investigação em Reumatologia, Instituto de Medicina Molecular, Lisboa, Portugal
| | - Sónia do Vale
- Serviço de Endocrinologia, Universidade de Lisboa Faculdade de Medicina, Lisboa, Portugal .,Hospital de Santa Maria, Serviço de Endocrinologia, Centro Hospitalar Lisboa Norte EPE, Lisboa, Portugal
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3
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Nikolaou N, Arvaniti A, Appanna N, Sharp A, Hughes BA, Digweed D, Whitaker MJ, Ross R, Arlt W, Penning TM, Morris K, George S, Keevil BG, Hodson L, Gathercole LL, Tomlinson JW. Glucocorticoids regulate AKR1D1 activity in human liver in vitro and in vivo. J Endocrinol 2020; 245:207-218. [PMID: 32106090 PMCID: PMC7182088 DOI: 10.1530/joe-19-0473] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 02/27/2020] [Indexed: 12/14/2022]
Abstract
Steroid 5β-reductase (AKR1D1) is highly expressed in human liver where it inactivates endogenous glucocorticoids and catalyses an important step in bile acid synthesis. Endogenous and synthetic glucocorticoids are potent regulators of metabolic phenotype and play a crucial role in hepatic glucose metabolism. However, the potential of synthetic glucocorticoids to be metabolised by AKR1D1 as well as to regulate its expression and activity has not been investigated. The impact of glucocorticoids on AKR1D1 activity was assessed in human liver HepG2 and Huh7 cells; AKR1D1 expression was assessed by qPCR and Western blotting. Genetic manipulation of AKR1D1 expression was conducted in HepG2 and Huh7 cells and metabolic assessments were made using qPCR. Urinary steroid metabolite profiling in healthy volunteers was performed pre- and post-dexamethasone treatment, using gas chromatography-mass spectrometry. AKR1D1 metabolised endogenous cortisol, but cleared prednisolone and dexamethasone less efficiently. In vitro and in vivo, dexamethasone decreased AKR1D1 expression and activity, further limiting glucocorticoid clearance and augmenting action. Dexamethasone enhanced gluconeogenic and glycogen synthesis gene expression in liver cell models and these changes were mirrored by genetic knockdown of AKR1D1 expression. The effects of AKR1D1 knockdown were mediated through multiple nuclear hormone receptors, including the glucocorticoid, pregnane X and farnesoid X receptors. Glucocorticoids down-regulate AKR1D1 expression and activity and thereby reduce glucocorticoid clearance. In addition, AKR1D1 down-regulation alters the activation of multiple nuclear hormone receptors to drive changes in gluconeogenic and glycogen synthesis gene expression profiles, which may exacerbate the adverse impact of exogenous glucocorticoids.
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Affiliation(s)
- Nikolaos Nikolaou
- Oxford Centre for Diabetes,
Endocrinology and Metabolism, NIHR Oxford Biomedical Research Centre,
University of Oxford, Churchill Hospital, Oxford, UK
| | - Anastasia Arvaniti
- Oxford Centre for Diabetes,
Endocrinology and Metabolism, NIHR Oxford Biomedical Research Centre,
University of Oxford, Churchill Hospital, Oxford, UK
- Department of Biological and Medical
Sciences, Oxford Brookes University, Oxford,
UK
| | - Nathan Appanna
- Oxford Centre for Diabetes,
Endocrinology and Metabolism, NIHR Oxford Biomedical Research Centre,
University of Oxford, Churchill Hospital, Oxford, UK
| | - Anna Sharp
- Oxford Centre for Diabetes,
Endocrinology and Metabolism, NIHR Oxford Biomedical Research Centre,
University of Oxford, Churchill Hospital, Oxford, UK
| | - Beverly A Hughes
- Institute of Metabolism and Systems
Research, University of Birmingham, Edgbaston, Birmingham,
UK
| | | | | | - Richard Ross
- Department of Oncology and
Metabolism, Faculty of Medicine, Dentistry and Health,
University of Sheffield, Sheffield, UK
| | - Wiebke Arlt
- Institute of Metabolism and Systems
Research, University of Birmingham, Edgbaston, Birmingham,
UK
- NIHR Birmingham Biomedical Research
Centre, University Hospitals Birmingham NHS Foundation Trust
and University of Birmingham, Birmingham, UK
| | - Trevor M Penning
- Department of Systems Pharmacology &
Translational Therapeutics, University of Pennsylvania Perelman
School of Medicine, Philadelphia, Pennsylvania, USA
| | - Karen Morris
- Biochemistry Department,
Manchester University NHS Trust, Manchester, UK
| | - Sherly George
- Biochemistry Department,
Manchester University NHS Trust, Manchester, UK
| | - Brian G Keevil
- Biochemistry Department,
Manchester University NHS Trust, Manchester, UK
| | - Leanne Hodson
- Oxford Centre for Diabetes,
Endocrinology and Metabolism, NIHR Oxford Biomedical Research Centre,
University of Oxford, Churchill Hospital, Oxford, UK
| | - Laura L Gathercole
- Oxford Centre for Diabetes,
Endocrinology and Metabolism, NIHR Oxford Biomedical Research Centre,
University of Oxford, Churchill Hospital, Oxford, UK
- Department of Biological and Medical
Sciences, Oxford Brookes University, Oxford,
UK
| | - Jeremy W Tomlinson
- Oxford Centre for Diabetes,
Endocrinology and Metabolism, NIHR Oxford Biomedical Research Centre,
University of Oxford, Churchill Hospital, Oxford, UK
- Correspondence should be addressed to J W Tomlinson:
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Vélez-Díaz-Pallarés M, Esteban-Cartelle B, Montero-Llorente B, Gramage-Caro T, Rodríguez-Sagrado MÁ, Bermejo-Vicedo T. Interactions of cobicistat and ritonavir in patients with HIV and its clinical consequences. Enferm Infecc Microbiol Clin 2019; 38:212-218. [PMID: 31753469 DOI: 10.1016/j.eimc.2019.09.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 09/13/2019] [Accepted: 09/21/2019] [Indexed: 12/14/2022]
Abstract
INTRODUCTION The prescription of antiretroviral treatment (ART) that contains pharmacokinetic enhancers such as ritonavir and cobicistat is frequent. The objective of this stdy was to analyze the potential interactions of ART that include these molecules in their formulation with the patient's home medication, as well as the clinical management of those potentially serious. METHODS Prospective study conducted in the pharmacy care clinic of a third level hospital between January and December of 2018. Those HIV+patients with an ART containing cobicistat or ritonavir were included in the study. Potential interactions between ART and concomitant medication were analysed in three databases (Micromedex®, Drugs.com and Liverpool), the interventions carried out were detailed, and adverse drug reactions analysed. RESULTS 968 patients were included with a total of 2,148 prescriptions (274 different medications). A total of 86 interventions were performed regarding potential interactions in patients. The most frequent were substitutions of corticoid treatments, treatment suspensions and closer monitoring of treatments. A total of possible adverse drug reactions were analysed. The degree of agreement in the severity classification of the interactions for cobicistat and ritonavir was good among the three databases. It was remarkable Micromedex® as the most complete because it has more registered medications. CONCLUSION The interactions between ART with pharmacokinetic enhancers in its composition and concomitant medication is frequent and requires a significant variety of interventions. The check of interactions in different databases is recommended since they can cause adverse drug reactions.
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Chary A, Nguyen NN, Maiton K, Holodniy M. A review of drug-drug interactions in older HIV-infected patients. Expert Rev Clin Pharmacol 2017; 10:1329-1352. [PMID: 28922979 DOI: 10.1080/17512433.2017.1377610] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION The number of older HIV-infected people is growing due to increasing life expectancies resulting from the use of antiretroviral therapy (ART). Both HIV and aging increase the risk of other comorbidities, such as cardiovascular disease, osteoporosis, and some malignancies, leading to greater challenges in managing HIV with other conditions. This results in complex medication regimens with the potential for significant drug-drug interactions and increased morbidity and mortality. Area covered: We review the metabolic pathways of ART and other medications used to treat medical co-morbidities, highlight potential areas of concern for drug-drug interactions, and where feasible, suggest alternative approaches for treating these conditions as suggested from national guidelines or articles published in the English language. Expert commentary: There is limited evidence-based data on ART drug interactions, pharmacokinetics and pharmacodynamics in the older HIV-infected population. Choosing and maintaining effective ART regimens for older adults requires consideration of side effect profile, individual comorbidities, interactions with concurrent prescriptions and non-prescription medications and supplements, dietary patterns with respect to dosing, pill burden and ease of dosing, cost and affordability, patient preferences, social situation, and ART resistance history. Practitioners must remain vigilant for potential drug interactions and intervene when there is a potential for harm.
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Affiliation(s)
- Aarthi Chary
- a Department of Medicine , Veterans Affairs Palo Alto Health Care System , Palo Alto , CA , USA.,b Division of Infectious Diseases and Geographic Medicine , Stanford University School of Medicine , Stanford , CA , USA
| | - Nancy N Nguyen
- c Department of Pharmacy , Veterans Affairs Palo Alto Health Care System , Palo Alto , CA , USA.,d Department of Pharmacy Practice, Thomas J. Long School of Pharmacy & Health Sciences , University of the Pacific , Stockton , CA , USA
| | - Kimberly Maiton
- d Department of Pharmacy Practice, Thomas J. Long School of Pharmacy & Health Sciences , University of the Pacific , Stockton , CA , USA
| | - Mark Holodniy
- a Department of Medicine , Veterans Affairs Palo Alto Health Care System , Palo Alto , CA , USA.,b Division of Infectious Diseases and Geographic Medicine , Stanford University School of Medicine , Stanford , CA , USA.,e Office of Public Health Surveillance & Research , Veterans Affairs Palo Alto Health Care System , Palo Alto , CA , USA
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Tiruneh F, Awan A, Didana A, Doshi S. Preventing Cushing: Iatrogenic Cushing Syndrome due to Ritonavir-Fluticasone Interaction. Cureus 2017; 9:e1484. [PMID: 28944123 PMCID: PMC5602273 DOI: 10.7759/cureus.1484] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Ritonavir is commonly used in low doses to boost plasma levels of protease inhibitors in patients with human immunodeficiency virus (HIV) infections. It is also a potent inhibitor of cytochrome P450. We present a 50-year-old African American male with past medical history of HIV on highly active antiretroviral therapy (HAART), which also included ritonavir and long standing asthma that has been treated with inhaled fluticasone, who presented with back pain. He had central obesity, prominent abdominal striae and wasted extremities on physical examination. Laboratory tests showed low morning serum cortisol and suboptimal cosyntropin test consistent with adrenal insufficiency. Computed tomography (CT) of the spine showed a fracture of inferior endplate of the lumbar (L3) vertebra. The cause of osteoporosis is believed to be iatrogenic Cushing syndrome caused by enhanced levels of inhaled fluticasone effects secondary to inhibition of cytochrome P450. The patient was managed surgically and fluticasone was discontinued.
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Affiliation(s)
- Fasil Tiruneh
- Department of Internal Medicine, Howard University Hospital
| | - Ahmad Awan
- Department of Internal Medicine, Howard University Hospital
| | - Abiot Didana
- Cardiovascular Technician, Inova Mount Vernon Hospital
| | - Saumil Doshi
- Department of Internal Medicine, Howard University Hospital
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Kinlein SA, Shahanoor Z, Romeo RD, Karatsoreos IN. Chronic Corticosterone Treatment During Adolescence Has Significant Effects on Metabolism and Skeletal Development in Male C57BL6/N Mice. Endocrinology 2017; 158:2239-2254. [PMID: 28510653 PMCID: PMC5505211 DOI: 10.1210/en.2017-00208] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2017] [Accepted: 01/24/2017] [Indexed: 01/06/2023]
Abstract
Glucocorticoids are potent modulators of metabolic and behavioral function. Their role as mediators in the "stress response" is well known, but arguably their primary physiological function is in the regulation of cellular and organismal metabolism. Disruption of normal glucocorticoid function is linked to metabolic disease, such as Cushing syndrome. Glucocorticoids are also elevated in many forms of obesity, suggesting that there are bidirectional effects of these potent hormones on metabolism and metabolic function. Adolescence is a time of rapid physical growth, and disruptions during this critical time likely have important implications for adult function. The hypothalamic-pituitary-adrenal axis continues to mature during this period, as do tissues that respond to glucocorticoids. In this work, we investigate how chronic noninvasive exposure to corticosterone affects metabolic outcomes (body weight, body composition, insulin, and glucose homeostasis), as well as changes in bone density in both adult and adolescent male mice. Specifically, we report a different pattern of metabolic effects in adolescent mice compared with adults, as well as an altered trajectory of recovery in adolescents and adults. Together, these data indicate the profound influence that adolescent development has on the metabolic outcomes of chronic corticosterone exposure, and describe a tractable model for understanding the short- and long-term impacts of hypercortisolemic states on physiological and neurobehavioral functions.
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Affiliation(s)
- Scott A. Kinlein
- Department of Integrative Physiology and Neuroscience, Washington State University, Pullman, Washington 99164
| | - Ziasmin Shahanoor
- Department of Psychology and Neuroscience and Behavior Program, Barnard College of Columbia University, New York, New York 10027
| | - Russell D. Romeo
- Department of Psychology and Neuroscience and Behavior Program, Barnard College of Columbia University, New York, New York 10027
| | - Ilia N. Karatsoreos
- Department of Integrative Physiology and Neuroscience, Washington State University, Pullman, Washington 99164
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Abstract
Adrenal insufficiency is characterised by inadequate -glucocorticoid production owing to destruction of the adrenal cortex or lack of adrenocorticotropic hormone stimulation. In primary adrenal insufficiency, lack of mineralocorticoids is also a feature. Patients can present with an insidious onset of symptoms, or acutely in adrenal crisis, which requires prompt recognition and treatment. Chronic glucocorticoid therapy is the most common cause of adrenal insufficiency. The -diagnosis of adrenal insufficiency is made by -demonstrating low basal and/or stimulated serum cortisol and should be -followed by appropriate investigations to establish the -underlying aetiology. Maintenance glucocorticoid -replacement is usually given as a twice or thrice daily hydrocortisone preparation. Patients with primary adrenal insufficiency also require mineralocorticoid. Regular monitoring for features of under- and over- replacement is essential during follow-up. Patient education is a key feature of management of this condition.
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Affiliation(s)
| | - Simon Hs Pearce
- Institute of Genetic Medicine, Newcastle University, Newcastle upon Tyne, UK
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van den Berg SAA, van 't Veer NE, Emmen JMA, van Beek RHT. Fluticasone furoate induced iatrogenic Cushing syndrome in a pediatric patient receiving anti-retroviral therapy. Endocrinol Diabetes Metab Case Rep 2017; 2017:EDM160158. [PMID: 28458904 PMCID: PMC5404706 DOI: 10.1530/edm-16-0158] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Accepted: 03/02/2017] [Indexed: 11/20/2022] Open
Abstract
Summary We present a case of iatrogenic Cushing’s syndrome, induced by treatment with fluticasone furoate (1–2 dd, 27.5 µg in each nostril) in a pediatric patient treated for congenital HIV. The pediatric patient described in this case report is a young girl of African descent, treated for congenital HIV with a combination therapy of Lopinavir/Ritonavir (1 dd 320/80 mg), Lamivudine (1 dd 160 mg) and Abacavir (1 dd 320 mg). Our pediatric patient presented with typical Cushingoid features (i.e. striae of the upper legs, full moon face, increased body and facial hair) within weeks after starting fluticasone furoate therapy, which was exacerbated after increasing the dose to 2 dd because of complaints of unresolved rhinitis. Biochemical analysis fitted iatrogenic Cushing’s syndrome, with a repeatedly low cortisol (<0.03 µM, ref 0.14–0.60 µM) and low ACTH (9 pg/mL, ref 9–52 pg/mL) without signs of adrenal insufficiency. No other biochemical abnormalities that could point to adrenal or pituitary dysfunction were detected; electrolytes, thyroid and gonadal function, and IGF-1 were within the normal range. Pharmacogenetic analysis revealed that the pediatric patient carried the CYP3A4 *1B/*1G and CYP3A5 *3/*3 genotype (associated with a partial and complete loss of enzyme activity, respectively) which is associated with the development of iatrogenic Cushing’s syndrome in patients treated for HIV due to the strong inhibition of CYP3 enzymes by Ritonavir. Upon discontinuation of fluticasone treatment, the pediatric patient improved both clinically and biochemically with normalisation of cortisol and ACTH within a couple of weeks. Learning points:
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Affiliation(s)
- S A A van den Berg
- Laboratory for Clinical Chemistry and Haematology, Amphia Hospital, BredaThe Netherlands.,Laboratory for Clinical Chemistry, Erasmus MC, RotterdamThe Netherlands
| | | | - J M A Emmen
- Laboratory for Clinical Chemistry and Haematology, Amphia Hospital, BredaThe Netherlands
| | - R H T van Beek
- Departments of Pediatrics, Amphia Hospital, BredaThe Netherlands
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10
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Efeito de exercícios físicos e de lazer sobre os níveis de cortisol plasmático em pacientes com Aids. REVISTA BRASILEIRA DE CIÊNCIAS DO ESPORTE 2016. [DOI: 10.1016/j.rbce.2014.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Iatrogenic Cushing's syndrome caused by intranasal steroid use. North Clin Istanb 2016; 4:97-99. [PMID: 28752153 PMCID: PMC5530168 DOI: 10.14744/nci.2016.38981] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Accepted: 01/24/2016] [Indexed: 11/20/2022] Open
Abstract
Cushing’s syndrome (CS) is common after oral steroid use and has also been reported following topical or inhaled use, but it is extremely uncommon after intranasal administration. This is the case of a 6-year-old child who developed Cushing’s syndrome after intranasal application of dexamethasone sodium phosphate for a period of 6 months. Pediatricians and other clinical practitioners should be aware that high-dose and long-term nasal steroid administration may cause iatrogenic Cushing’s syndrome characterized by complications of glucocorticoid excess as well as serious and even life-threatening complications of adrenal insufficiency.
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Woods CP, Argese N, Chapman M, Boot C, Webster R, Dabhi V, Grossman AB, Toogood AA, Arlt W, Stewart PM, Crowley RK, Tomlinson JW. Adrenal suppression in patients taking inhaled glucocorticoids is highly prevalent and management can be guided by morning cortisol. Eur J Endocrinol 2015; 173:633-42. [PMID: 26294794 PMCID: PMC4588051 DOI: 10.1530/eje-15-0608] [Citation(s) in RCA: 102] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Accepted: 08/20/2015] [Indexed: 02/06/2023]
Abstract
CONTEXT Up to 3% of US and UK populations are prescribed glucocorticoids (GC). Suppression of the hypothalamo-pituitary-adrenal axis with the potential risk of adrenal crisis is a recognized complication of therapy. The 250 μg short Synacthen stimulation test (SST) is the most commonly used dynamic assessment to diagnose adrenal insufficiency. There are challenges to the use of the SST in routine clinical practice, including both the staff and time constraints and a significant recent increase in Synacthen cost. METHODS We performed a retrospective analysis to determine the prevalence of adrenal suppression due to prescribed GCs and the utility of a morning serum cortisol for rapid assessment of adrenal reserve in the routine clinical setting. RESULTS In total, 2773 patients underwent 3603 SSTs in a large secondary/tertiary centre between 2008 and 2013 and 17.9% (n=496) failed the SST. Of 404 patients taking oral, topical, intranasal or inhaled GC therapy for non-endocrine conditions, 33.2% (n=134) had a subnormal SST response. In patients taking inhaled GCs without additional GC therapy, 20.5% (34/166) failed an SST and suppression of adrenal function increased in a dose-dependent fashion. Using receiver operating characteristic curve analysis in patients currently taking inhaled GCs, a basal cortisol ≥348 nmol/l provided 100% specificity for passing the SST; a cortisol value <34 nmol/l had 100% sensitivity for SST failure. Using these cut-offs, 50% (n=83) of SSTs performed on patients prescribed inhaled GCs were unnecessary. CONCLUSION Adrenal suppression due to GC treatment, particularly inhaled GCs, is common. A basal serum cortisol concentration has utility in helping determine which patients should undergo dynamic assessment of adrenal function.
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Affiliation(s)
- Conor P Woods
- Oxford Centre for Diabetes Endocrinology and Metabolism (OCDEM)NIHR Biomedical Research Centre, Churchill Hospital, University of Oxford, Headington, Oxford OX3 7LJ, UKCentre for EndocrinologyDiabetes and Metabolism, University of Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UKDepartment of EndocrinologyFaculty of Medicine and Psychology, St Andrea Hospital, Sapienza University of Rome, Rome, ItalyDepartments of BiochemistryHealth InformaticsQueen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UKDepartment of EndocrinologyUniversity of Leeds, Leeds, UK
| | - Nicola Argese
- Oxford Centre for Diabetes Endocrinology and Metabolism (OCDEM)NIHR Biomedical Research Centre, Churchill Hospital, University of Oxford, Headington, Oxford OX3 7LJ, UKCentre for EndocrinologyDiabetes and Metabolism, University of Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UKDepartment of EndocrinologyFaculty of Medicine and Psychology, St Andrea Hospital, Sapienza University of Rome, Rome, ItalyDepartments of BiochemistryHealth InformaticsQueen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UKDepartment of EndocrinologyUniversity of Leeds, Leeds, UK Oxford Centre for Diabetes Endocrinology and Metabolism (OCDEM)NIHR Biomedical Research Centre, Churchill Hospital, University of Oxford, Headington, Oxford OX3 7LJ, UKCentre for EndocrinologyDiabetes and Metabolism, University of Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UKDepartment of EndocrinologyFaculty of Medicine and Psychology, St Andrea Hospital, Sapienza University of Rome, Rome, ItalyDepartments of BiochemistryHealth InformaticsQueen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UKDepartment of EndocrinologyUniversity of Leeds, Leeds, UK
| | - Matthew Chapman
- Oxford Centre for Diabetes Endocrinology and Metabolism (OCDEM)NIHR Biomedical Research Centre, Churchill Hospital, University of Oxford, Headington, Oxford OX3 7LJ, UKCentre for EndocrinologyDiabetes and Metabolism, University of Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UKDepartment of EndocrinologyFaculty of Medicine and Psychology, St Andrea Hospital, Sapienza University of Rome, Rome, ItalyDepartments of BiochemistryHealth InformaticsQueen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UKDepartment of EndocrinologyUniversity of Leeds, Leeds, UK
| | - Christopher Boot
- Oxford Centre for Diabetes Endocrinology and Metabolism (OCDEM)NIHR Biomedical Research Centre, Churchill Hospital, University of Oxford, Headington, Oxford OX3 7LJ, UKCentre for EndocrinologyDiabetes and Metabolism, University of Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UKDepartment of EndocrinologyFaculty of Medicine and Psychology, St Andrea Hospital, Sapienza University of Rome, Rome, ItalyDepartments of BiochemistryHealth InformaticsQueen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UKDepartment of EndocrinologyUniversity of Leeds, Leeds, UK
| | - Rachel Webster
- Oxford Centre for Diabetes Endocrinology and Metabolism (OCDEM)NIHR Biomedical Research Centre, Churchill Hospital, University of Oxford, Headington, Oxford OX3 7LJ, UKCentre for EndocrinologyDiabetes and Metabolism, University of Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UKDepartment of EndocrinologyFaculty of Medicine and Psychology, St Andrea Hospital, Sapienza University of Rome, Rome, ItalyDepartments of BiochemistryHealth InformaticsQueen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UKDepartment of EndocrinologyUniversity of Leeds, Leeds, UK
| | - Vijay Dabhi
- Oxford Centre for Diabetes Endocrinology and Metabolism (OCDEM)NIHR Biomedical Research Centre, Churchill Hospital, University of Oxford, Headington, Oxford OX3 7LJ, UKCentre for EndocrinologyDiabetes and Metabolism, University of Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UKDepartment of EndocrinologyFaculty of Medicine and Psychology, St Andrea Hospital, Sapienza University of Rome, Rome, ItalyDepartments of BiochemistryHealth InformaticsQueen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UKDepartment of EndocrinologyUniversity of Leeds, Leeds, UK
| | - Ashley B Grossman
- Oxford Centre for Diabetes Endocrinology and Metabolism (OCDEM)NIHR Biomedical Research Centre, Churchill Hospital, University of Oxford, Headington, Oxford OX3 7LJ, UKCentre for EndocrinologyDiabetes and Metabolism, University of Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UKDepartment of EndocrinologyFaculty of Medicine and Psychology, St Andrea Hospital, Sapienza University of Rome, Rome, ItalyDepartments of BiochemistryHealth InformaticsQueen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UKDepartment of EndocrinologyUniversity of Leeds, Leeds, UK
| | - Andrew A Toogood
- Oxford Centre for Diabetes Endocrinology and Metabolism (OCDEM)NIHR Biomedical Research Centre, Churchill Hospital, University of Oxford, Headington, Oxford OX3 7LJ, UKCentre for EndocrinologyDiabetes and Metabolism, University of Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UKDepartment of EndocrinologyFaculty of Medicine and Psychology, St Andrea Hospital, Sapienza University of Rome, Rome, ItalyDepartments of BiochemistryHealth InformaticsQueen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UKDepartment of EndocrinologyUniversity of Leeds, Leeds, UK
| | - Wiebke Arlt
- Oxford Centre for Diabetes Endocrinology and Metabolism (OCDEM)NIHR Biomedical Research Centre, Churchill Hospital, University of Oxford, Headington, Oxford OX3 7LJ, UKCentre for EndocrinologyDiabetes and Metabolism, University of Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UKDepartment of EndocrinologyFaculty of Medicine and Psychology, St Andrea Hospital, Sapienza University of Rome, Rome, ItalyDepartments of BiochemistryHealth InformaticsQueen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UKDepartment of EndocrinologyUniversity of Leeds, Leeds, UK
| | - Paul M Stewart
- Oxford Centre for Diabetes Endocrinology and Metabolism (OCDEM)NIHR Biomedical Research Centre, Churchill Hospital, University of Oxford, Headington, Oxford OX3 7LJ, UKCentre for EndocrinologyDiabetes and Metabolism, University of Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UKDepartment of EndocrinologyFaculty of Medicine and Psychology, St Andrea Hospital, Sapienza University of Rome, Rome, ItalyDepartments of BiochemistryHealth InformaticsQueen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UKDepartment of EndocrinologyUniversity of Leeds, Leeds, UK
| | - Rachel K Crowley
- Oxford Centre for Diabetes Endocrinology and Metabolism (OCDEM)NIHR Biomedical Research Centre, Churchill Hospital, University of Oxford, Headington, Oxford OX3 7LJ, UKCentre for EndocrinologyDiabetes and Metabolism, University of Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UKDepartment of EndocrinologyFaculty of Medicine and Psychology, St Andrea Hospital, Sapienza University of Rome, Rome, ItalyDepartments of BiochemistryHealth InformaticsQueen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UKDepartment of EndocrinologyUniversity of Leeds, Leeds, UK
| | - Jeremy W Tomlinson
- Oxford Centre for Diabetes Endocrinology and Metabolism (OCDEM)NIHR Biomedical Research Centre, Churchill Hospital, University of Oxford, Headington, Oxford OX3 7LJ, UKCentre for EndocrinologyDiabetes and Metabolism, University of Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UKDepartment of EndocrinologyFaculty of Medicine and Psychology, St Andrea Hospital, Sapienza University of Rome, Rome, ItalyDepartments of BiochemistryHealth InformaticsQueen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UKDepartment of EndocrinologyUniversity of Leeds, Leeds, UK
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Epperla N, McKiernan F. Iatrogenic Cushing syndrome and adrenal insufficiency during concomitant therapy with ritonavir and fluticasone. SPRINGERPLUS 2015; 4:455. [PMID: 26322261 PMCID: PMC4549367 DOI: 10.1186/s40064-015-1218-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Accepted: 08/06/2015] [Indexed: 11/12/2022]
Abstract
Ritonavir is a potent inhibitor of the cytochrome P450 enzyme CYP3A4 and is subject to multiple drug–drug interactions. This becomes especially important when the patient is also taking medications metabolized through CYP3A pathway as increased and potentially toxic drug levels may ensue. Herein we present one such interaction wherein a 57 year old gentleman with human immunodeficiency virus (HIV) infection on highly active antiretroviral therapy that included ritonavir, had addition of fluticasone inhaler to his medication repertoire for treatment of chronic obstructive pulmonary disease. This resulted in severe osteoporosis, iatrogenic Cushing syndrome and adrenal insufficiency due to the potentiated systemic glucocorticoid effect of inhaled fluticasone by ritonavir. This case emphasizes the need for pharmacovigilance when managing patients on complex drug regimens for physicians treating HIV infected patients.
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Affiliation(s)
- Narendranath Epperla
- Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, WI USA
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14
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Putcha N, Drummond MB, Wise RA, Hansel NN. Comorbidities and Chronic Obstructive Pulmonary Disease: Prevalence, Influence on Outcomes, and Management. Semin Respir Crit Care Med 2015; 36:575-91. [PMID: 26238643 DOI: 10.1055/s-0035-1556063] [Citation(s) in RCA: 110] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Comorbidities impact a large proportion of patients with chronic obstructive pulmonary disease (COPD), with over 80% of patients with COPD estimated to have at least one comorbid chronic condition. Guidelines for the treatment of COPD are just now incorporating comorbidities to their management recommendations of COPD, and it is becoming increasingly clear that multimorbidity as well as specific comorbidities have strong associations with mortality and clinical outcomes in COPD, including dyspnea, exercise capacity, quality of life, healthcare utilization, and exacerbation risk. Appropriately, there has been an increased focus upon describing the burden of comorbidity in the COPD population and incorporating this information into existing efforts to better understand the clinical and phenotypic heterogeneity of this group. In this article, we summarize existing knowledge about comorbidity burden and specific comorbidities in COPD, focusing on prevalence estimates, association with outcomes, and existing knowledge about treatment strategies.
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Affiliation(s)
- Nirupama Putcha
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland
| | - M Bradley Drummond
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Robert A Wise
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Nadia N Hansel
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland
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15
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Gómez-Cerquera JM, Hernando-López E, Blanco-Ramos JR. Insuficiencia suprarrenal iatrogénica por la interacción entre ritonavir y fluticasona inhalada. Revisión de la literatura. Enferm Infecc Microbiol Clin 2014; 32:662-5. [DOI: 10.1016/j.eimc.2013.12.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2013] [Revised: 12/16/2013] [Accepted: 12/24/2013] [Indexed: 10/25/2022]
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16
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HIV-associated obstructive lung diseases: insights and implications for the clinician. THE LANCET RESPIRATORY MEDICINE 2014; 2:583-92. [PMID: 24831854 DOI: 10.1016/s2213-2600(14)70017-7] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
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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17
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García-Martín E, Canto G, Agúndez JAG. Metabolic considerations of drugs in the treatment of allergic diseases. Expert Opin Drug Metab Toxicol 2013; 9:1437-52. [PMID: 23902458 DOI: 10.1517/17425255.2013.823400] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION The clinical management of allergic diseases involves a number of drugs, most of which are extensively metabolized. This review aims to analyze the metabolism and the clinical implications of altered metabolism for these drugs. AREAS COVERED The authors present an overview of current knowledge of the metabolism of: antihistamine drugs, glucocorticoids, inhaled β-2 bronchodilators, anticholinergics and other drugs used in allergic diseases, such as cromoglycate, omalizumab, montelukast and epinephrine. Polymorphic drug metabolism is relevant for chlorpheniramine, loratadine and montelukast. Inhibition of drug metabolism is relevant for loratadine, methylprednisolone, fluticasone, mometasone, triamcinolone or prednisolone. Polymorphic pre-systemic metabolism may be relevant to budesonide, fluticasone, beclomethasone, mometasone or salmeterol. The authors also discuss the current information on gene variations according to the 1,000 genomes catalog and other databases. Finally, the authors review the clinical implications of these variations with a particular regard to drugs used in the management of allergic diseases. EXPERT OPINION Most drugs used in allergic diseases are extensively metabolized. Drug interaction or adverse reactions related to altered metabolism are relevant issues that should be considered in the management of allergic diseases. However, much additional research is required before defining pharmacogenomic biomarkers for the management of drugs used in allergic diseases.
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Affiliation(s)
- Elena García-Martín
- University of Extremadura, Department of Biochemistry & Molecular Biology , Avda. de la Universidad s/n, E-10071, Cáceres , Spain +34927257000 ext 89676 ;
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18
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Boyd SD, Hadigan C, McManus M, Chairez C, Nieman LK, Pau AK, Alfaro RM, Kovacs JA, Calderon MM, Penzak SR. Influence of low-dose ritonavir with and without darunavir on the pharmacokinetics and pharmacodynamics of inhaled beclomethasone. J Acquir Immune Defic Syndr 2013; 63:355-61. [PMID: 23535292 PMCID: PMC3683093 DOI: 10.1097/qai.0b013e31829260d6] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To identify an alternative inhaled corticosteroid to fluticasone propionate that can be safely coadministered with HIV protease inhibitors, the safety and pharmacokinetics of beclomethasone dipropionate (BDP) and its active metabolite, beclomethasone 17-monopropionate (17-BMP), in combination with ritonavir (RTV) and darunavir/ritonavir (DRV/r) were assessed. DESIGN Open-label, prospective, randomized pharmacokinetic and pharmacodynamic study in healthy volunteers. METHODS Thirty healthy volunteers received inhaled 160 μg bid BDP for 14 days and were then randomized (1:1:1) into 3 groups: group 1 (control) remained on BDP alone for 28 days, group 2 received 100 mg bid BDP + RTV for 28 days, and group 3 received 600/100 mg bid BDP + DRV/r for 28 days. Pharmacokinetic sampling for 17-BMP was performed on days 14 and 28, and pharmacokinetic parameter values were compared within patients and between groups. Cortisol stimulation testing was also performed on days 1, 14, 28, and 42 and compared within and between groups. RESULTS Geometric mean ratios (day 28:day 14) (90% confidence interval) for 17-BMP area under the concentration-time curve in groups 1, 2, and 3, respectively, were 0.93 (0.81 to 1.06, P = 0.27), 2.08 (1.52 to 2.65, P = 0.006), and 0.89 (0.68 to 1.09, P = 0.61). There were no significant reductions in serum cortisol levels within or between groups (P > 0.05). CONCLUSIONS DRV/r did not increase 17-BMP exposure, whereas RTV alone produced a statistically significant but clinically inconsequential 2-fold increase in 17-BMP exposure. Adrenal suppression was not observed in any of the study groups. These data suggest that BDP can be safely coadministered with DRV/r and likely other RTV-boosted protease inhibitors.
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Affiliation(s)
- Sarita D Boyd
- Office of Safety and Epidemiology, US Food and Drug Administration, Silver Spring, MD 20993, USA.
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19
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Saberi P, Phengrasamy T, Nguyen DP. Inhaled corticosteroid use in HIV-positive individuals taking protease inhibitors: a review of pharmacokinetics, case reports and clinical management. HIV Med 2013; 14:519-29. [PMID: 23590676 DOI: 10.1111/hiv.12039] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/03/2013] [Indexed: 11/29/2022]
Abstract
As a consequence of inhibition of the hepatic cytochrome P450 3A4 isozyme, treatment with 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 and iatrogenic Cushing's syndrome (with symptoms such as rapid weight gain, obesity, facial hirsutism and swelling), 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 suggest options for the clinical management of HIV-positive patients requiring treatment with protease inhibitors and inhaled or intranasal corticosteroids.
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Affiliation(s)
- P Saberi
- Department of Medicine, University of California, San Francisco, CA, USA
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Dutta D, KS S, Ghosh S, Mukhopadhyay S, Chowdhury S. Iatrogenic Cushing's syndrome following short-term intranasal steroid use. J Clin Res Pediatr Endocrinol 2012; 4:157-9. [PMID: 22985615 PMCID: PMC3459166 DOI: 10.4274/jcrpe.726] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Cushing's syndrome (CS) is common after oral steroid use and has also been reported following topical or inhaled use, but it is extremely uncommon after intranasal administration. In this paper, we present the case of a child who developed CS after intranasal application of combined moxifloxacin-dexamethasone eye drops for epistaxis for a period of 3 months. CS caused by ocular preparations of steroids has not been reported previously. This case report highlights the fact that even eye drops can contain high doses of steroids and can lead to CS especially in children and especially if used intranasally. Ocular steroid drops should not be used intranasally. To minimize gastrointestinal absorption and therefore the risk of CS, nasal sprays should be preferred over nasal drops for intranasal steroid application.
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Affiliation(s)
- Deep Dutta
- IPGMER & SSKM Hospital, Department of Endocrinology & Metabolism, Kolkata, India.
| | - Shivaprasad KS
- IPGMER & SSKM Hospital, Department of Endocrinology & Metabolism, Kolkata, India
| | - Sujoy Ghosh
- IPGMER & SSKM Hospital, Department of Endocrinology & Metabolism, Kolkata, India
| | | | - Subhankar Chowdhury
- IPGMER & SSKM Hospital, Department of Endocrinology & Metabolism, Kolkata, India
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Current world literature. Curr Opin Endocrinol Diabetes Obes 2012; 19:328-37. [PMID: 22760515 DOI: 10.1097/med.0b013e3283567080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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