Adrenal suppression and Cushing's syndrome secondary to an interaction between ritonavir and fluticasone: a review of the literature
- 8 July 2008
- journal article
- review article
- Published by Wiley in HIV Medicine
- Vol. 9 (6), 389-396
- https://doi.org/10.1111/j.1468-1293.2008.00579.x
Abstract
The 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.A literature search using Medline and EMBASE and a search of abstracts of the three previous years of major HIV-related conferences were carried out.There 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.The combination of ritonavir and fluticasone should be avoided. Budesonide, beclomethasone, triamcinolone and flunisolide appear to be safer options.Keywords
This publication has 33 references indexed in Scilit:
- Cushing Syndrome and Severe Adrenal Suppression Caused by Fluticasone and Protease Inhibitor Combination in an HIV-Infected AdolescentAIDS Patient Care and STDs, 2007
- Iatrogenic Cushing's syndrome in a adolescent with AIDSs on ritonavir and inhaled fluticasone. case report and literature reviewAIDS, 2007
- Ritonavir–Fluticasone Interaction Causing Cushing Syndrome in HIV-Infected Children and AdolescentsThe Pediatric Infectious Disease Journal, 2006
- Cushing syndrome with secondary adrenal insufficiency from concomitant therapy with ritonavir and fluticasoneThe Journal of Pediatrics, 2006
- Cushing's syndrome without excess cortisolBMJ, 2006
- Iatrogenic Cushing's syndrome in an HIV-infected patient treated with ritonavir and inhaled fluticasoneAIDS, 2005
- Exogenous glucocorticoid excess as a result of ritonavir–fluticasone interactionInternal Medicine Journal, 2005
- The effect of a steroid “burst” and long-term, inhaled fluticasone propionate on adrenal reserveAnnals of Allergy, Asthma & Immunology, 2003
- Exogenous Cushing Syndrome Mimicking Human Immunodeficiency Virus LipodystrophyClinical Infectious Diseases, 2002
- Profound adrenal suppression secondary to treatment with low dose inhaled steroids and itraconazole in allergic bronchopulmonary aspergillosis in cystic fibrosisThorax, 2002