Iatrogenic Cushing syndrome and adrenal insufficiency during concomitant therapy with ritonavir and fluticasone

Abstract

Ritonavir is a potent inhibitor of the cytochrome P450 enzyme CYP3A4 and is subject to multiple drug-drug interactions. This becomes especially important when the patient is also taking medications metabolized through CYP3A pathway as increased and potentially toxic drug levels may ensue. Herein we present one such interaction wherein a 57 year old gentleman with human immunodeficiency virus (HIV) infection on highly active antiretroviral therapy that included ritonavir, had addition of fluticasone inhaler to his medication repertoire for treatment of chronic obstructive pulmonary disease. This resulted in severe osteoporosis, iatrogenic Cushing syndrome and adrenal insufficiency due to the potentiated systemic glucocorticoid effect of inhaled fluticasone by ritonavir. This case emphasizes the need for pharmacovigilance when managing patients on complex drug regimens for physicians treating HIV infected patients.

Keywords: Cytochrome P450; Fluticasone; Human immunodeficiency virus; Ritonavir.

Fig. 1

Centripetal adiposity, multiple ecchymoses and pronounced pink abdominal and inguinal striae

Fig. 2

Chest X-ray showing numerous rib fractures

Fig. 3

Markedly improved abdominal and inguinal striae as well as the ecchymotic lesions

Fig. 4

DXA trend after withdrawal of ritonavir and treatment with teriparatide along with depiction of improved trabecular bone scores