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Ritonavir, Inhaled Fluticasone Interact to Create Cushing’s Syndrome Symptoms: Presented at AAAAI By Carole VanSickle Ellis NEW ORLEANS -- March 3, 2010 -- A potent inhibitor of cytochrome P450 that is often used in patients with HIV may interact with inhaled fluticasone to create a condition of adrenal suppression and symptoms that can result in a diagnosis of Cushing’s syndrome that may not be entirely accurate, said researchers here on February 28 at the 2010 American Academy of Allergy, Asthma & Immunology (AAAAI) Annual Meeting. Keren Malev-Guri, MD, Neve-Or AIDS Center Kaplan Medical Center, Rehovot, Israel, and colleagues evaluated clinical appearance, diagnosis, and management of 3 patients with HIV being treated with a highly active antiretroviral therapy (HAART) regimen that included ritonavir, and who presented with adrenal suppression and Cushing’s syndrome after using inhaled fluticasone for asthma exacerbations. The 3 female patients (aged 12, 55, and 65 years) presented with the “moon face” facial swelling associated with Cushing’s syndrome, increased weight, and fatigue after treatment. Initially, the diagnosis was HAART-induced lipodystrophy, but lab work revealed low morning blood cortisol and low 24-hour urinary free-cortisol levels with an abnormal (flat) Synacthen test, leading to a diagnosis of Cushing’s syndrome with adrenal insufficiency. However, with the graduated discontinuation of fluticasone, the abnormalities resolved. One patient successfully replaced fluticasone with budesonide, another inhaled corticosteroid, and continued the ritonavir without clinical or lab abnormalities. Dr. Malev-Guri said that the diagnosis of Cushing’s syndrome in patients with HIV receiving HAART should be considered challenging and suspect in all patients treated with ritonavir and inhaled fluticasone because the ritonavir significantly increases fluticasone levels in the system thanks to the inhibition of CYP3A4. After the diagnosis, fluticasone should be discontinued gradually, and adrenal functions must be closely monitored. The researchers concluded that the combination of ritonavir and fluticasone should be avoided, and if an inhaled corticosteroid is necessary, then another corticosteroid such as budesonide should be used. [Presentation title: Adrenal Suppression and Cushing’s Syndrome Due to the Interaction Between Ritonavir and Inhaled Fluticasone. Abstract E-mail this page to a friend or colleague! To print, use this version