Prevalence of subclinical iatrogenic cushing's syndrome (ics) in patients being co-administered ritonavir and corticosteroids via inhaled, intranasal and/or topical route
Background: Although ICS has been reported in patients receiving ritonavir and long-acting inhaled corticosteroids, the prevalence of ICS is unknown. The risk of ICS with co-administration of ritonavir and nasal/topical corticosteroids has not been reported.
Methods: In a clinical practice of >2200 patients, 172 were identified as receiving both ritonavir and inhaled/nasally sprayed, and/or topical steroids. An AM serum cortisol level (SCL) and adrenocorticotropic hormone (ACTH) level was ordered on 64 patients based on duration and extent of corticosteroid use (≥1 month and ≥4.5% of total body surface area for topicals). ICS was defined as a SCL ≤4.5mcg/dL. Low ACTH value was defined as ≤10 pg/mL. Medians (interquartile range) and non-parametric statistical methods are reported.
Results: The SCL of 34 patients with results reported are available. Topical steroids (TS) were used by 4, nasally sprayed (NSS) by 10, and inhaled (IS) by 20. Overall, 12/34 (35%) met the diagnosis of ICS [1/4 TS; 3/10 NSS; and 8/20 IS]. The median SCL for those who met the ICS criteria was 1.25 (0.7, 2.6) and among the remainder the SCL median level was 14.3 (11.4, 16.6)(p< 0.0001). Unexpectedly, median SCL or ACTH were not different between the three groups (Table 1.). SCL and ACTH values correlated with each other (Spearman rank coefficient=0.71;p< 0.0001).
| Topical Steroids | Nasally Sprayed Steroids | Inhaled Steroids | p values | |
| Median Serum Cortisol Levels micrograms/dL (interquartile range) | 12.9 (4.3, 16.1) | 14.8 (8.6, 17.7) | 8.8 (1.2, 13.4) | 0.14 |
| Median ACTH Levels picograms/mL (interquartile range) | 18.0 (12.2, 22.2) | 19.0 (6.0, 27.5) | 22.0 (7.0, 37.0) | 0.85 |
Conclusions: An unsuspected high rate of ICS of 35% was uncovered. Although SCL tended to be lower in the IS group, there was no statistically significant difference between corticosteroid route of administration which highlights the risk that exists for all patients on ritonavir and any chronic steroid, irrespective of route of administration. We recommend all patients on ritonavir and chronic steroids be tested for ICS.
R. Okasaki-Gutierrez1, P. Poole1,2, P. Troia-Concio1,2, D.M. Asmuth1
1University of California Davis Medical Center, Sacramento, United States, 2CARES Clinic, Sacramento, United States