title: High frequency of hypothalamic-pituitary-adrenal axis dysfunction after local corticosteroid injection in HIV-infected patients on protease inhibitor therapy.
abstract: BACKGROUND
  The frequency of hypothalamic-pituitary-adrenal axis dysfunction among HIV-infected patients receiving steroid injections has not been reported, and the risk factors for this adverse event are poorly characterized.
  
  
  METHODS
  We conducted a retrospective analysis of data from HIV-infected patients in the Partners HealthCare system (Boston, MA) who received corticosteroid injection(s) between 2002 and 2011. Chart review focused on HIV status, antiretroviral therapy [eg, protease inhibitors (PI)], steroid injection(s), and adrenal axis dysfunction (eg, adrenal insufficiency and/or Cushing syndrome). Because all cases occurred among patients on PIs, we performed additional detailed data extraction and conducted univariate and multivariate analyses to identify risk factors in this group.
  
  
  RESULTS
  One hundred seventy-one HIV-infected patients received ≥1 corticosteroid injection(s) in the study period. Nine cases (event frequency: 5.3%; 95% confidence interval: 2.4% to 9.8%) of secondary adrenal insufficiency were diagnosed; 5 (55%) of these 9 patients also had clinical evidence of Cushing syndrome. All cases occurred among the 81 patients on PIs (event frequency among those on PIs: 11.1%; 95% confidence interval: 5.2% to 20.0%). Among patients on PIs, the major risk factor for hypothalamic-pituitary-adrenal axis dysfunction was having ≥2 injections within 6 months.
  
  
  CONCLUSIONS
  In this retrospective cohort study, 11% of HIV-infected patients on PIs at the time of steroid injection were later diagnosed with hypothalamic-pituitary-adrenal axis dysfunction. Corticosteroid injections in HIV-infected patients on PIs should only be used with great caution and close monitoring.
authors.affiliation: *Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA; †Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA; ‡Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA; §Division of Infectious Diseases, Brigham and Women's Hospital, Boston, MA; ‖Department of Pharmacy, Massachusetts General Hospital, Boston, MA; ¶Research Design Center/Biostatistics Research Center, Clinical and Translational Science Institute, Tufts University, Boston, MA; #Division of Endocrinology, Yale University School of Medicine, New Haven, CT; **Division of Endocrinology, Massachusetts General Hospital, Boston, MA; ††Department of Newborn Medicine, Brigham and Women's Hospital, Boston, MA; ‡‡Harvard University Center for AIDS Research, Boston, MA; §§Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, MA; and ‖‖Ragon Institute of Massachusetts General Hospital, MIT and Harvard, Charlestown, MA.
authors.forename: Emily P
authors.initials: EP
authors.lastname: Hyle
authors.forename: Brian R
authors.initials: BR
authors.lastname: Wood
authors.forename: Elke S
authors.initials: ES
authors.lastname: Backman
authors.forename: Farzad
authors.initials: F
authors.lastname: Noubary
authors.forename: Janice
authors.initials: J
authors.lastname: Hwang
authors.forename: Zhigang
authors.initials: Z
authors.lastname: Lu
authors.forename: Elena
authors.initials: E
authors.lastname: Losina
authors.forename: Rochelle P
authors.initials: RP
authors.lastname: Walensky
authors.forename: Rajesh T
authors.initials: RT
authors.lastname: Gandhi
mesh_terms: D000305:Adrenal Cortex Hormones / Q000009:adverse effects* / Q000627:therapeutic use; D000311:Adrenal Glands / Q000187:drug effects*; D000309:Adrenal Insufficiency / Q000139:chemically induced*; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001900:Boston; D005260:Female; D015658:HIV Infections / Q000188:drug therapy*; D017320:HIV Protease Inhibitors / Q000009:adverse effects / Q000627:therapeutic use*; D006801:Humans; D007031:Hypothalamus / Q000187:drug effects*; D008297:Male; D008875:Middle Aged; D010902:Pituitary Gland / Q000187:drug effects*; D012189:Retrospective Studies
chemical_list: D000305:Adrenal Cortex Hormones; D017320:HIV Protease Inhibitors