fluticasone-propionate--salmeterol-xinafoate-drug-combination and Cushing-Syndrome

Physicians are not always aware that locally administered glucocorticoids can cause systemic toxicity. This risk is greatly enhanced in the case of pharmacological interactions. We present two cases of HIV-infected patients who developed Cushing-like symptoms as a result of a pharmacological interaction. Their antiretroviral treatment regimen consisted of atazanavir, ritonavir, tenofovir and emtricitabine. One patient received salmeterol/fluticasone inhalations for asthmatic bronchitis. The other was treated with intra-articular triamcinolonacetonide injections for ongoing shoulder complaints. Ritonavir exhibits strong inhibition of hepatic enzyme CYP 3A4, which is part of the major metabolic pathway of most glucocorticoids. As a result of this interaction even locally administered glucocorticoids can cause symptoms of overdose, e.g. Cushing-like symptoms. Beclomethasone is a safe alternative for inhaled glucocorticoids as it is not metabolized by CYP 3A4. There is no substitute for intra-articular administration of triamcinolonacetonide. Depending on necessity of the administration of the drug, changing ritonavir-containing antiretroviral therapy to a non-interacting compound, e.g., an integrase inhibitor, is an option.

Topics: Adult; Albuterol; Androstadienes; Asthma; Bronchodilator Agents; Cushing Syndrome; Cytochrome P-450 CYP3A; Cytochrome P-450 CYP3A Inhibitors; Drug Combinations; Drug Interactions; Fluticasone-Salmeterol Drug Combination; Glucocorticoids; HIV Infections; HIV Protease Inhibitors; Humans; Male; Ritonavir

Topics: Administration, Inhalation; Albuterol; Androstadienes; Asthma; Cushing Syndrome; Drug Combinations; Fluticasone-Salmeterol Drug Combination; Glucocorticoids; Humans; Male; Young Adult

Topics: Administration, Inhalation; Adrenal Cortex Hormones; Adult; Albuterol; Androstadienes; Cushing Syndrome; Drug Combinations; Drug Interactions; Female; Fluticasone-Salmeterol Drug Combination; HIV Infections; HIV Protease Inhibitors; Humans; Iatrogenic Disease; Ritonavir