Iatrogenic Cushing's syndrome, diabetes mellitus and secondary adrenal failure in a human immunodeficiency virus patient treated with ritonavir boosted atazanavir and fluticasone

Ritonavir and atazanavir (ATZ) are protease inhibitors (PI) that inhibit the P450 3A4 cytochrome. They are used together to boost ATZ levels and reduce pill burden in human immunodeficiency virus infection, but association with medications metabolized by this cytochrome can cause serious adverse eff...

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Bibliographic Details
Published in:Annales d'endocrinologie 2009-09, Vol.70 (4), p.252-255
Main Authors: Collet-Gaudillat, C, Roussin-Bretagne, S, Desforges-Bullet, V, Petit-Aubert, G, Doll, J, Beressi, J -P
Format: Article
Language:fre
Subjects:
Administration, Inhalation
Adrenocorticotropic Hormone - blood
Androstadienes - adverse effects
Blood Glucose - metabolism
Bronchodilator Agents - adverse effects
Creatinine - metabolism
Cushing Syndrome - complications
Cushing Syndrome - drug therapy
Diabetes Complications - drug therapy
Diet, Diabetic
Fluticasone
Glycated Hemoglobin A - metabolism
HIV Infections - complications
HIV Infections - drug therapy
HIV Protease Inhibitors - adverse effects
HIV-2
Humans
Hydrocortisone - blood
Hydrocortisone - therapeutic use
Male
Middle Aged
Ritonavir - adverse effects
Thyroxine - blood
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Summary:Ritonavir and atazanavir (ATZ) are protease inhibitors (PI) that inhibit the P450 3A4 cytochrome. They are used together to boost ATZ levels and reduce pill burden in human immunodeficiency virus infection, but association with medications metabolized by this cytochrome can cause serious adverse effects. Several cases of Cushing's syndrome have been reported when patients received inhaled therapy with fluticasone for asthma, sometimes complicated by secondary adrenal failure after stopping fluticasone. We report a case of Cushing's syndrome associated with onset of diabetes mellitus in a patient treated with boosted PI (ATZ and ritonavir) for HIV 2 (CD4360/ml). Asthma was treated with inhaled fluticasone 1500mug/day for several months that was stopped at admission. A few days later, typical secondary adrenal failure developed and was confirmed by dosage of cortisol and ACTH, both low. Hydrocortisone replacement treatment resulted in rapid improvement of symptoms. Diabetes was initially treated with insulin then sulfonyluraes, but repeated hypoglycemias lead to diet alone. Physicians should be aware of the potential danger of the association of "boosted" IP and some kind of inhaled corticotherapy.
ISSN:0003-4266
DOI:10.1016/j.ando.2009.02.017