Iatrogenic Cushing Syndrome After Epidural Steroid Injections for Lumbar Radiculopathy in an HIV‐Infected Patient Treated With Ritonavir: A Case Report Highlighting Drug Interactions for Spine Interventionalists

Grierson, Matthew J.; Harrast, Mark A.

doi:10.1016/j.pmrj.2011.10.003

Cited by 22 publications

(18 citation statements)

References 8 publications

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“…More severe manifestations occurred in some patients including hyperglycemic hyperosmolar state [7], as well as avascular necrosis of the hip [8]. One patient had a rather delayed diagnosis with the fat distribution changes thought of as due to lipodystrophy [11]. The lowest dose of triamcinolone administered was a one-time 40 mg injection, and the highest was cumulative dose of 240 mg of triamcinolone given as 3 injections of 80 mg dose each.…”

Section: Review Of Other Casesmentioning

confidence: 99%

“…The symptoms may be as subtle as change in weight distribution/weight gain that may be mistaken for lipodystrophy and the diagnosis may therefore be delayed potentially for months [11]. The more severe presentations reported include hypertension, glucose intolerance to the point of hyperglycemic hyperosmotic state, metabolic syndrome, and avascular necrosis resulting in significant morbidity [5–15].…”

Section: Review Of Other Casesmentioning

confidence: 99%

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Iatrogenic Cushing Syndrome Secondary to Ritonavir-Epidural Triamcinolone Interaction: An Illustrative Case and Review

Sadarangani

Berg

Mauck

et al. 2014

Interdisciplinary Perspectives on Infectious Diseases

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HIV positive patients on ritonavir-containing antiretroviral therapy (ART) can develop iatrogenic Cushing syndrome (IACS) and adrenal insufficiency as a result of drug-drug interactions with inhaled or intranasal glucocorticoid therapy. Reports related to epidural triamcinolone injections are relatively uncommon but increasingly reported. We describe a 48-year-old woman with immunologically and virologically well-controlled HIV on ritonavir-based ART, who developed headache, dizziness, and candida and herpes simplex virus (HSV) ulcerative esophagitis 7 days after receiving an epidural triamcinolone injection for cervical radicular pain. Iatrogenic Cushing syndrome and relative adrenal insufficiency were suspected and proven. The patient's ART was changed to a non-HIV protease inhibitor- (PI-) containing program, her symptoms improved, and she did not require hydrocortisone replacement. In this paper, we review the literature on IACS and relative secondary adrenal insufficiency from epidural triamcinolone injections in HIV patients on ritonavir-containing ART regimens. A high index of clinical suspicion is needed for diagnosis. Prevention of drug-drug interactions by taking a thorough medication history for patients on ritonavir-containing ART regimens before prescribing any form of corticosteroid is crucial and effective and sustained interdisciplinary communication in the care of such patients.

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Section: Review Of Other Casesmentioning

confidence: 99%

Section: Review Of Other Casesmentioning

confidence: 99%

Iatrogenic Cushing Syndrome Secondary to Ritonavir-Epidural Triamcinolone Interaction: An Illustrative Case and Review

Sadarangani

Berg

Mauck

et al. 2014

Interdisciplinary Perspectives on Infectious Diseases

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“…12,19,20 This was comparable to symptom improvement seen in cases where patients were switched to non-PI-based regimens. Ritonavir-boosted PI regimens are preferred over unboosted PI regimens in the treatment of HIV.…”

Section: Experience Injectable Steroid-ritonavir Interactionmentioning

confidence: 60%

“…The patient's presentation was consistent with previous reports of ICS, which describe onset of clinical symptoms within several weeks of drug exposure (range, 1 week to 5 months). [12][13][14][15][16][17][18][19][20][21] Before presentation, our patient had been immunologically stable for years. At presentation, a significant drop in CD4 cell count without loss of virologic suppression was noted in our patient, resulting in advanced immunosuppression (CD4 cell count <200 cells/mm 3 ).…”

Section: Discussionmentioning

confidence: 99%

“…13,16,20 This case report adds to the growing body of literature describing adrenal suppression and ICS as a result of the drug-drug interaction between ritonavir and injectable forms of corticosteroids. [12][13][14][15][16][17][18][19][20][21] Although rare, there may be clinically important morbidity associated with interaction between ritonavir and a single injection of triamcinolone in patients living with HIV. Our patient, whose HIV had been stable for a number of years, experienced loss of immune function requiring treatment of oral candidiasis and herpes, as well as prophylaxis for opportunistic infections.…”

Section: Experience Injectable Steroid-ritonavir Interactionmentioning

confidence: 99%

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Iatrogenic Cushing's syndrome after triamcinolone plus ritonavir-boosted atazanavir

Jakeman

Conklin

Bouchonville

et al. 2015

Journal of the American Pharmacists Association

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Systemic Absorption and Side Effects of Locally Injected Glucocorticoids

Stout

Friedly

Standaert

2019

PM&R

108

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Local glucocorticoid injections are often used to treat joint, soft tissue, or spinal pain, but the systemic side effects associated with these injections are poorly understood and not well recognized. There are significant known risks to systemic administration of glucocorticoids. However, there are no guidelines that address issues of systemic absorption, overall systemic risks, or other side effects of locally injected glucocorticoids. For this review, a literature search was performed, and the available evidence on systemic absorption and clinical side effects of intra‐articular and epidural glucocorticoids was synthesized. The goal was to improve clinical understanding of risks associated with these injections. Existing data suggest there is significant individual variability in the amount of systemic absorption and clinical effects of locally injected glucocorticoids. However, it is clear that both intra‐articular and epidural injections can have systemic effects for weeks and that complications may be associated with their use, including Cushing syndrome, loss of bone density, infection, and hyperglycemia. The concurrent use of oral steroids, the number of injections, and the type and dose of glucocorticoids used all are important considerations in estimating risks. The total dose calculation of cumulative glucocorticoid exposure should include all local injections. Caution should be exercised when local glucocorticoid injections are used in higher risk patients, such as postmenopausal women, people with diabetes, and those considering surgery in the near term. Better provider awareness of possible systemic risks should improve decision making and informed consent with patients when considering intra‐articular and epidural steroid injections for painful conditions. Level of Evidence IV

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Iatrogenic Cushing Syndrome After Epidural Steroid Injections for Lumbar Radiculopathy in an HIV‐Infected Patient Treated With Ritonavir: A Case Report Highlighting Drug Interactions for Spine Interventionalists

Cited by 22 publications

References 8 publications

Iatrogenic Cushing Syndrome Secondary to Ritonavir-Epidural Triamcinolone Interaction: An Illustrative Case and Review

Iatrogenic Cushing Syndrome Secondary to Ritonavir-Epidural Triamcinolone Interaction: An Illustrative Case and Review

Iatrogenic Cushing's syndrome after triamcinolone plus ritonavir-boosted atazanavir

Systemic Absorption and Side Effects of Locally Injected Glucocorticoids

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