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Iatrogenic Cushing's Syndrome in HIV-Infected Patients Receiving Ritonavir and Inhaled Fluticasone: Description of 4 New Cases and Review of the Literature

Service de Maladies Infectieuses et Tropicales, APHP, Hôpital Saint-Louis, 75010 Paris, France, nadia.valin{at}wanadoo.fr

Nathalie De Castro, MD

Service de Maladies Infectieuses et Tropicales, APHP, Hôpital Saint-Louis, 75010 Paris, France

Valerie Garrait, MD

Service de Medecine Interne et Hépato-gastroentérologie, Centre Hospitalier Intercommunal de Créteil, 94000 Créteil, France

Anne Bergeron, MD

Service de Pneumologie, APHP, Hôpital Saint-Louis, 75010 Paris, France

Clara Bouche, MD

Service de Diabétologie et d'Endocrinologie, APHP, Hôpital Saint-Louis, 75010 Paris, France

Jean Michel Molina, MD, PhD

Service de Maladies Infectieuses et Tropicales, APHP, Hôpital Saint-Louis, 75010 Paris, France

Protease inhibitors boosted with ritonavir can lead to drug—drug interactions, particularly with inhaled corticosteroids such as fluticasone, because of the potent inhibition of cytochrome P450-3A4 activity. We report 4 cases of iatrogenic Cushing's syndrome after concomitant administration of inhaled fluticasone and antiretroviral therapy including a protease inhibitor boosted with ritonavir. Although typical manifestations were present, diagnosis of Cushing's syndrome was delayed because the patients were suspected to have antiretroviral therapy-associated lipodystrophy, which shares common clinical features with Cushing's syndrome. Biochemical tests confirmed iatrogenic Cushing's syndrome and clinical symptoms resolved after stopping ritonavir or fluticasone. The differences between the clinical symptoms of Cushing's syndrome and lipodystrophy are discussed as well as their frequency in the cases reported in the literature. The recommendation that concomitant administration of inhaled or intranasal fluticasone and ritonavir be prohibited must be implemented among practitioners who treat HIV-infected patients, and if long-term inhaled steroids are required, other drugs should be preferred.

Key Words: drug—drug interaction • AIDS • inhaled steroids • ritonavir • fluticasone

This version was published on March 1, 2009

Journal of the International Association of Physicians in AIDS Care (JIAPAC), Vol. 8, No. 2, 113-121 (2009)
DOI: 10.1177/1545109709332019


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