Cushing syndrome and severe adrenal suppression caused by fluticasone and protease inhibitor combination in an HIV-infected adolescent.
A 14-year-old female with perinatally acquired HIV on boosted protease inhibitor (PI) therapy with atazanavir and ritonavir rapidly developed cushingoid features with excessive weight gain and moon facies within 2 weeks of receiving inhaled fluticasone/salmeterol for asthma treatment. Soon after discontinuing PIs and inhaled steroid, she required hospitalization for dyspnea, headache, muscle weakness, and extreme fatigue requiring hydrocortisone replacement therapy for presumed adrenal insufficiency. Cushing syndrome and adrenal suppression were very likely caused by elevated steroid systemic concentrations resulting from the cytochrome p450 interaction between the protease inhibitors and fluticasone. The Naranjo probability scale score of 5 suggests that the event was probably drug related. This is the first case report of fluticasone and PI-induced Cushing syndrome and adrenal suppression in a pediatric patient without a history of recent or concomitant treatment with systemic steroid therapy. Additionally, this case is unique as it is the most rapid (<2 weeks) presentation documented, thus far. Health care professionals should be conscious of this important drug-drug interaction in HIV-infected children and adolescents and be aware that rapid onset of hypercortisolism and adrenal suppression are possible.
St Germain
Renee M
RM
University of Connecticut School of Pharmacy, Department of Pharmacy Practice, Storrs, Connecticut, USA.
Yigit
Sevket
S
Wells
Lorraine
L
Girotto
Jennifer E
JE
Giratto
Jennifer E
JE
Salazar
Juan C
JC
D000293:Adolescent; D000309:Adrenal Insufficiency / Q000139:chemically induced*; D000420:Albuterol / Q000031:analogs & derivatives; D000730:Androstadienes / Q000009:adverse effects*; D019380:Anti-HIV Agents / Q000009:adverse effects; D000893:Anti-Inflammatory Agents / Q000009:adverse effects; D000069446:Atazanavir Sulfate; D003480:Cushing Syndrome / Q000139:chemically induced*; D004347:Drug Interactions; D004359:Drug Therapy, Combination; D005260:Female; D000068298:Fluticasone; D015658:HIV Infections / Q000188:drug therapy*; D006801:Humans; D006854:Hydrocortisone / Q000627:therapeutic use; D009842:Oligopeptides / Q000009:adverse effects*; D011725:Pyridines / Q000009:adverse effects*; D019438:Ritonavir / Q000009:adverse effects*; D000068299:Salmeterol Xinafoate
D000730:Androstadienes; D019380:Anti-HIV Agents; D000893:Anti-Inflammatory Agents; D009842:Oligopeptides; D011725:Pyridines; D000069446:Atazanavir Sulfate; D000068299:Salmeterol Xinafoate; D000068298:Fluticasone; D019438:Ritonavir; D000420:Albuterol; D006854:Hydrocortisone