Category: Adrenal Disorders
Ritonavir is a protease inhibitor commonly used in the treatment of Human Immunodeficiency Virus (HIV) infection. Ritonavir is also an inhibitor of Cytochrome P450 3A4 isoenzyme. Inhibition of this isoenzyme slows down drug metabolism. Thus, drugs metabolized by this pathway tend to accumulate in the system for e.g. Ketoconazole, Fluticasone etc. Interestingly inhaled steroids can accumulate in the body and causes negative feedback resulting in adrenocortical insufficiency.
Methods : N/A
We are reporting an interesting case of a 51 year old male with the history of HIV, Sarcoidosis, Diabetes and Asthma who was found to have iatrogenic Cushing's syndrome secondary to Ritonavir and Fluticasone therapy. He subsequently developed hypotensive shock from secondary adrenal insufficiency.Our patient was first diagnosed with multidrug resistant HIV in 1992, and he was successfully treated with Ritonavir, Dolutegravir, Emtricitabine-Tenofovir and Maraviroc. He was taking hydroxychloroquine for his Sarcoidosis and his asthma was well controlled with Fluticasone inhaler taken twice a day for the past three years.The patient initially presented to the infectious diseases clinic with severe dry cough, bilateral pedal edema, abdominal striae and expanding visceral obesity. His laboratory results were consistent with a diagnosis of Cushing’s syndrome with ACTH levels
On day seven, he presented to the emergency department with hypotension (systolic blood pressure <80mmHg), dry cough and shortness of breath. His lab results were consistent with severe adrenocortical insufficiency (cortisol=0.7mcg/dl, the normal range is 4-22mcg/dl. The respiratory viral panel returned positive for Human metapneumovirus. Endocrine was consulted and they managed him with stress doses of Hydrocortisone and was treated conservatively for his upper respiratory viral infection. His symptoms of weakness and shortness of breath improved over time and blood pressure normalized. The adrenal insufficiency was attributed to Ritonavir and Fluticasone. Fluticasone inhaler was stopped and the patient was given albuterol nebulization for asthma.
This case is of clinical relevance because inhaled corticosteroids are commonly used for the treatment of Asthma and concomitant use of Ritonavir can have life-threatening consequences. Although this drug interaction is rare because inhaled corticosteroids have minimal systemic effects, Ritonavir can inhibit the metabolism of fluticasone leading to suppression of the hypothalamic-pituitary axis.
Conclusion : We have concluded after a thorough literature review that physicians should be vigilant of these rare but significant drug interactions for effective patient care.
Syeda Naqvi– Physician, Presence health, Chicago, Illinois
Faisal Qureshi– Chief Section of Endocrinology, Presence Saint Joseph Hospital Chicago, chicago
Tooba Hisham– Medical Graduate, Dow International Medical College, Ontario, Canada
Thomas Varghese– Resident Physician, Saint Joseph Hospital Chicago, chicago, Illinois
Currently working as a first year resident at Presence Saint Joseph Hospital. Interested in the field of Endocrinology
Chief Section of Endocrinology
Presence Saint Joseph Hospital Chicago
Dow International Medical College, Ontario, Canada