Iatrogenic Cushing Syndrome after Epidural Triamcinolone Injections in an HIV Type 1–Infected Patient Receiving Therapy with Ritonavir‐Lopinavir

Abstract

We report the first case of a human immunodeficiency virus type 1 (HIV-1)-infected individual receiving combination antiretroviral therapy, which included ritonavir, who developed Cushing syndrome with profound complications after epidural triamcinolone injections. This case highlights the potential of ritonavir interactions even with local injections of a corticosteroid.

Iatrogenic Cushing's Syndrome Due to Pharmacokinetic Interaction of Intra-Ocular Corticosteroids and Lopinavir/Ritonavir in an HIV-Infected Adolescent: A Case Report

“…Patients who develop Cushing's syndrome may require replacement therapy with corticosteroids and gradual tapering with special consideration of the potential use of "stress dose" replacement steroids in times of acute illness or trauma. Iatrogenic Cushing's syndrome and secondary adrenal suppression have recently been reported in adult patients receiving ritonavir with a single intraarticular or epidural injection of triamcinolone acetonide [13][14][15][16]. Duration of hypothalamic pituitary axis suppression was from 5-8 months in these case reports, suggesting the persistence of systemic triamcinolone plasma concentrations and prolonged suppression of adrenal function.…”

“…Even short-term corticosteroid therapy has been associated with iatrogenic Cushing's syndrome and adrenal suppression in HIV-infected patients receiving protease inhibitors. Pharmacokinetic drug interactions caused by inhibition of the metabolism by ritonavir of various corticosteroids have been demonstrated with oral, inhaled (including intranasal), and intra-articular administration [11][12][13][14][15][16].…”

Important Drug-Drug Interactions in HIV-Infected Persons on Antiretroviral Therapy: An Update on New Interactions Between HIV and Non-HIV Drugs

“…It is postulated that the interaction may be more pronounced with fluticasone than other inhaled steroids due to unique pharmacokinetic characteristics such as high lipophilicity, a large volume of distribution, a long half-life and an increase affinity for the corticosteroid receptor [37•]. However, recent cases of adrenal suppression with the coadministration of ritonavir and other steroids, including injectable triamcinolone, [40][41][42][43] inhaled or oral budesonide, [44][45][46] and corticosteroid topical eye drops and ointment [47] have been reported.…”

“…There have been 7 cases of Cushing's syndrome reported with the use of intra-articular triamcinolone injections in patients on ritonavir-boosted cART regimens (100-200 mg daily of ritonavir) [40][41][42][43]. In most cases cushingoid symptoms and profound adrenal suppression (i.e.…”

“…low or undetectable morning cortisol and adrenocoticotropic hormone (ACTH)) presented about 2 weeks after a single injection of triamcinolone acetonide 40-80 mg. Three cases required supplemental oral hydrocortisone 10-30 mg daily for up to 8 months [40,41]. Antiretroviral therapy was held or changed in two cases [42,43]. Most cases resolved after several months; however there were two reports of avascular necrosis of the hip [40,43] occurring at 2 and 11 months post-steroid exposure, respectively.…”