The issue came up in terms of adverse effects (i.e., iatrogenic cushings) in patients on HIV cocktail containing ritonivir and use of even local steroids (the issue being that ritonivir is an extremely potent inhibitor of\u00a0CYP 3A4 , leading to excessive increases in circulating levels of drugs metabolized through this system). I brought up this question\u00a0with HIV providers in San Francisco (the HIV consult line) and received the following answer:<\/p>\n
–The case reported involved a patient with periradicular\u00a0injection of 20mg of\u00a0triamcinolone acetonide weekly for 6 weeks\u00a0for lower back pain, who\u00a0then developed severe cushingoid facies, central obesity, buffalo hump and proximal muscle weakness of her legs, as well as marked hypokalemia. Her HIV treatment included ritonivir 100mg bid\u00a0for 6 years, with a CD4 of 820 and suppressed viral load. The symptoms\u00a0of cushings began 6 week after her first injection. Work-up\u00a0confirmed suppressed ACTH and cortisol levels.<\/p>\n
–15 cases reported in the literature with suppression of hypothalamic-pituitary-adrenal (HPA)\u00a0axis\u00a0after injection with triamcinolone.\u00a0\u200bOf the 15 reported cases, 9 were women, mean dose of injected triamcinolone was 97mg (40-240) and mean number of injections was 1.6 (1 injection in 9 cases), all were on 100-200 mg ritonavir<\/p>\n
\u200b–specifically 4 injections were intra-articular (which presumably has\u00a0less systemic absorption than IM), 3 of these 4 had total dose of only 40\u00a0mg. symptoms began 2 weeks after injections and lasted 4-8 months afterwards. 2 patients with epidural injections had avascular necrosis. (So, a single injection of 40mg triamcinolone can lead to complete suppression of the HPA axis for up to 8 months!!<\/strong>)<\/p>\n \u00a0–methylprednisolone may be a reasonable therapeutic option (reduced dose methylprednisolone — 20-40\u00a0mg– was suggested in the radiology literature (ref 9 in the article)\u00a0and “may present lower risk”, but with the caveat that there are insufficient cases to know for sure if this is safe. in that article they suggested checking an am cortisol level 2 weeks after the injection.<\/p>\n Note: this becomes more of an issue given the (rather remarkable and fortunate) aging of the HIV population, as HIV has evolved into\u00a0a chronic condition, and\u00a0living longer, as we know, is associated with more musculoskeletal problems.\u00a0\u00a0But, the good news is that for most patients, there are great non-protease inhibitor options. So, seems that the safest thing would be to change the HIV regimen prior to putting someone on inhaled steroids or injectable ones. if that were not feasible, makes sense to use the ones not implicated above\u00a0and at the lowest dose you can\u00a0(with the rather large caveat that the identified cases are possibly found because of the more frequent use of inhaled\u00a0fluticasone or injected triamcinolone in the population, instead of their really being the bad actors here).<\/p>\n Geoff<\/p>\n","protected":false},"excerpt":{"rendered":" Avoid giving steroids with ritonivir!! […]<\/p>\n