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Case report
peer-reviewed

Preventing Cushing: Iatrogenic Cushing Syndrome due to Ritonavir-Fluticasone Interaction



Abstract

Ritonavir is commonly used in low doses to boost plasma levels of protease inhibitors in patients with human immunodeficiency virus (HIV) infections. It is also a potent inhibitor of cytochrome P450. We present a 50-year-old African American male with past medical history of HIV on highly active antiretroviral therapy (HAART), which also included ritonavir and long standing asthma that has been treated with inhaled fluticasone, who presented with back pain. He had central obesity, prominent abdominal striae and wasted extremities on physical examination. Laboratory tests showed low morning serum cortisol and suboptimal cosyntropin test consistent with adrenal insufficiency. Computed tomography (CT) of the spine showed a fracture of inferior endplate of the lumbar (L3) vertebra. The cause of osteoporosis is believed to be iatrogenic Cushing syndrome caused by enhanced levels of inhaled fluticasone effects secondary to inhibition of cytochrome P450. The patient was managed surgically and fluticasone was discontinued.



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Case report
peer-reviewed

Preventing Cushing: Iatrogenic Cushing Syndrome due to Ritonavir-Fluticasone Interaction


Author Information

Fasil Tiruneh Corresponding Author

Department of Internal Medicine, Howard University Hospital

Ahmad Awan

Department of Internal Medicine, Howard University Hospital

Abiot Didana

Cardiovascular Technician, Inova Mount Vernon Hospital

Saumil Doshi

Department of Internal Medicine, Howard University Hospital


Ethics Statement and Conflict of Interest Disclosures

Human subjects: Consent was obtained by all participants in this study. Conflicts of interest: The authors have declared that no conflicts of interest exist.


Case report
peer-reviewed

Preventing Cushing: Iatrogenic Cushing Syndrome due to Ritonavir-Fluticasone Interaction


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Case report
peer-reviewed

Preventing Cushing: Iatrogenic Cushing Syndrome due to Ritonavir-Fluticasone Interaction

  • Author Information
    Fasil Tiruneh Corresponding Author

    Department of Internal Medicine, Howard University Hospital

    Ahmad Awan

    Department of Internal Medicine, Howard University Hospital

    Abiot Didana

    Cardiovascular Technician, Inova Mount Vernon Hospital

    Saumil Doshi

    Department of Internal Medicine, Howard University Hospital


    Ethics Statement and Conflict of Interest Disclosures

    Human subjects: Consent was obtained by all participants in this study. Conflicts of interest: The authors have declared that no conflicts of interest exist.

    Acknowledgements


    Article Information

    Published: July 17, 2017

    DOI

    10.7759/cureus.1484

    Cite this article as:

    Tiruneh F, Awan A, Didana A, et al. (July 17, 2017) Preventing Cushing: Iatrogenic Cushing Syndrome due to Ritonavir-Fluticasone Interaction. Cureus 9(7): e1484. doi:10.7759/cureus.1484

    Publication history

    Received by Cureus: July 04, 2017
    Peer review began: July 07, 2017
    Peer review concluded: July 09, 2017
    Published: July 17, 2017

    Copyright

    © Copyright 2017
    Tiruneh et al. This is an open access article distributed under the terms of the Creative Commons Attribution License CC-BY 3.0., which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

    License

    This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Abstract

Ritonavir is commonly used in low doses to boost plasma levels of protease inhibitors in patients with human immunodeficiency virus (HIV) infections. It is also a potent inhibitor of cytochrome P450. We present a 50-year-old African American male with past medical history of HIV on highly active antiretroviral therapy (HAART), which also included ritonavir and long standing asthma that has been treated with inhaled fluticasone, who presented with back pain. He had central obesity, prominent abdominal striae and wasted extremities on physical examination. Laboratory tests showed low morning serum cortisol and suboptimal cosyntropin test consistent with adrenal insufficiency. Computed tomography (CT) of the spine showed a fracture of inferior endplate of the lumbar (L3) vertebra. The cause of osteoporosis is believed to be iatrogenic Cushing syndrome caused by enhanced levels of inhaled fluticasone effects secondary to inhibition of cytochrome P450. The patient was managed surgically and fluticasone was discontinued.



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Fasil Tiruneh, M.D.

Department of Internal Medicine, Howard University Hospital

For correspondence:
fasment2000@gmail.com

Ahmad Awan, M.D., Resident Physician

Department of Internal Medicine, Howard University Hospital

Abiot Didana

Cardiovascular Technician, Inova Mount Vernon Hospital

Saumil Doshi

Department of Internal Medicine, Howard University Hospital

Fasil Tiruneh, M.D.

Department of Internal Medicine, Howard University Hospital

For correspondence:
fasment2000@gmail.com

Ahmad Awan, M.D., Resident Physician

Department of Internal Medicine, Howard University Hospital

Abiot Didana

Cardiovascular Technician, Inova Mount Vernon Hospital

Saumil Doshi

Department of Internal Medicine, Howard University Hospital