Budesonide/ritonavir interaction
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Cushing syndrome in an elderly patient: case report A 75-year-old man developed Cushing syndrome while receiving ritonavir and budesonide. The man, who had hypertension, was receiving ritonavir 100mg daily [route and duration of treatment not stated] for HIV infection, as well as atazanavir, nevirapine and lamivudine. He was hospitalised with worsening chronic diarrhoea and rectal bleeding, and started receiving oral budesonide 3mg three times daily for lymphocytic colitis. His diarrhoea improved, but he was hospitalised again 12 days later with severe leg and facial swelling, a 10.4kg weight gain and uncontrolled hypertension. His BP was 177/102 mmHg (125/75 mmHg at previous hospitalisation), and he had cushingoid facies and 2+ pedal and pretibial oedema to his knees. Laboratory tests revealed the following: serum creatinine 1.3 mg/dL, potassium 2.8 mEq/L, bicarbonate 32 mg/dL, albumin 3.1 g/dL, brain natriuretic peptide 292 pg/mL, TSH 7.5 mIU/L, free thyroxine 1.07 ng/dL and serum cortisol 0.8 µg/dL. Amlodipine, hydralazine and furosemide were started for the man’s hypertension and oedema. After 3 weeks of treatment, budesonide was discontinued because of persistent severe oedema. Alternating treatment with loperamide and diphenoxylate/atropine eventually controlled the diarrhoea. Fifteen days after budesonide was discontinued, the oedema was resolved. At this time, his serum potassium level was 4.6 mEq/L and his bicarbonate level was 23 mg/dL. All his symptoms resolved. Author comment: "[R]itonavir has been most closely tied to adverse interactions with steroids. . . The Naranjo probability scale and Horn Drug Interaction Probability Scale score characterized [an interaction between ritonavir and budesonide] as a probable drug interaction." Frankel JK, et al. Cushing’s syndrome due to antiretroviral-budesonide interaction. Annals of Pharmacotherapy 45: 823-824, No. 6, Jun 2011. Available from: URL: 803057774 http://dx.doi.org/10.1345/aph.1p731 - USA
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Reactions 23 Jul 2011 No. 1361
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