Iatrogenic Cushing syndrome in HIV patients: analysis of the pharmacological interaction between steroids and ritonavir





Cushing's Syndrome; Endocrinology; HIV.


Introduction: Aids is a disease characterized by a deficiency of the immune system and which, in the past, brought great social stigma and low life expectancy to its patients. Associated with the increase in life expectancy, new health issues emerged among this population related to both aging and the vulnerability of HIV, which resulted in the inherent complexity of the pharmacological management of these diseases concomitant with antiretroviral therapy and their inadvertent iatrogenic risks, thus highlighting the interaction between Ritonavir. Method: A literature review was carried out in the online databases of the Virtual Health Library (VHL), using the descriptors: "Iatrogenic Cushing's syndrome" AND “HIV” from 2011 to 2021. Results and discussion: 24 articles found, 2 were literature reviews with an approach to the relationship between HIV and iatrogenic Cushing's syndrome and 22 corresponded to case reports that had based on patients with HIV in association with chronic diseases developed by age, with emphasis on musculoskeletal, respiratory and rheumatological disorders. Due to this combination, polypharmacy was applied, with the use of corticosteroids and antiretroviral therapy with Ritonavir the convergent pharmacological factor among all cases, as well as the main clinical manifestation: Cushing's Syndrome. Conclusion: It was noted that the use of exogenous glucocorticoids, like Triamcinolone, Fluticasone and Budesonide stand out, which interact with Ritonavir, in patients taking antiretroviral therapy for HIV can induce clinical presentations of Cushing's syndrome.


Albert, N. E., Kazi, S., Santoro, J., & Dougherty, R. (2012). Ritonavir and epidural triamcinolone as a cause of iatrogenic Cushing’s syndrome. The American journal of the medical sciences, 344(1), 72-74.

Alidoost, M., Conte, G. A., Agarwal, K., Carson, M. P., Lann, D., & Marchesani, D. (2020). Iatrogenic Cushing’s syndrome following intra-articular triamcinolone injection in an HIV-infected patient on cobicistat presenting as a pulmonary embolism: case report and literature review. International Medical Case Reports Journal, 13, 229.

Arce, S. C. B., & Aveiro, A. (2018). Complicaciones del uso prolongado de corticoides: Cushing iatrogénico. Revista Virtual de la Sociedad Paraguaya de Medicina Interna, 30-37.

Azevedo, L., Pêgo, H., Moura, T. S., & Germano, I. (2015). Iatrogenic Cushing's syndrome and osteoporosis due to an interaction between fluticasone and ritonavir. Case Reports, 2015, bcr2015211080.

Blondin, M. C., Beauregard, H., & Serri, O. (2013). Iatrogenic Cushing syndrome in patients receiving inhaled budesonide and itraconazole or ritonavir: two cases and literature review. Endocrine Practice, 19(6), e138-e141.

Colpitts, L., Murray, T. B., Tahhan, S. G., & Boggs, J. P. (2017). Iatrogenic cushing syndrome in a 47-year-old HIV-positive woman on ritonavir and inhaled budesonide. Journal of the International Association of Providers of AIDS Care (JIAPAC), 16(6), 531-534.

de Araújo, L. F., Teva, I., & de la Paz Bermúdez, M. (2014). Psychological and socio-demographic variables associated with sexual risk behavior for sexually transmitted infections/HIV. International Journal of Clinical and Health Psychology, 14(2), 120-127.

Dubrocq, G., Estrada, A., Kelly, S., & Rakhmanina, N. (2017). Acute development of Cushing syndrome in an HIV-infected child on atazanavir/ritonavir based antiretroviral therapy. Endocrinology, diabetes & metabolism case reports, 2017(1).

Epperla, N., & McKiernan, F. (2015). Iatrogenic Cushing syndrome and adrenal insufficiency during concomitant therapy with ritonavir and fluticasone. Springerplus, 4(1), 1-7.

Figueiredo, J. M. N. (2017). Síndrome de Cushing iatrogénica por interacção entre Fluticasona inalada e Ritonavir (Doctoral dissertation).

Fonseca, L. K. D. S., Santos, J. V. D. O., Araújo, L. F. D., & Sampaio, A. V. F. C. (2020). Análise da estigmatização no contexto do HIV/AIDS: Concepções de Pessoas que Vivem com HIV/AIDS. Gerais: Revista Interinstitucional de Psicologia, 13(2), 1-15.

Grierson, M. J., & Harrast, M. A. (2012). Iatrogenic Cushing syndrome after epidural steroid injections for lumbar radiculopathy in an HIV‐infected patient treated with ritonavir: a case report highlighting drug interactions for spine interventionalists. PM&R, 4(3), 234-237.

Hall, J. J., Hughes, C. A., Foisy, M. M., Houston, S., & Shafran, S. (2013). Iatrogenic Cushing syndrome after intra-articular triamcinolone in a patient receiving ritonavir-boosted darunavir. International journal of STD & AIDS, 24(9), 748-752.

Jakeman, B., Conklin, J., Bouchonville, M., & Thornton, K. (2015). Iatrogenic Cushing's syndrome after triamcinolone plus ritonavir-boosted atazanavir. Journal of the American Pharmacists Association, 55(2), 193-197.

John, G. R., Ollo, D., Meyer, P., Samer, C. F., & Calmy, A. (2013). Pulmonary embolism and iatrogenic Cushing's syndrome after co-administration of injected-triamcinolone and ritonavir. Aids, 27(17), 2827-2828.

John, G. R., Ollo, D., Meyer, P., Herold, M., Samer, C. F., & Calmy, A. (2013). Clinical course and management of iatrogenic Cushing’s syndrome after co-administration of injected-triamcinolone and Ritonavir: a systematic review. Journal of Antivirals and Antiretrovirals, 5(07).

Kant, R., Cromer, M. D., Chandra, R., Munir, K., & Verma, V. (2020). Avascular Necrosis of Both Hips From Iatrogenic Cushing’s Syndrome due to Coadministration of Fluticasone and Ritonavir in an HIV-Infected Patient. Cureus, 12(8).

Levine, D., Ananthakrishnan, S., & Garg, A. (2011). Iatrogenic Cushing syndrome after a single intramuscular corticosteroid injection and concomitant protease inhibitor therapy. Journal of the American Academy of Dermatology, 65(4), 877-878.

Mahlab-Guri, K., Asher, I., Gradstein, S., Zung, A., Radian-Sade, S., Elbirt, D., & Sthoeger, Z. (2011). Inhaled fluticasone causes iatrogenic cushing’s syndrome in patients treated with Ritonavir. Journal of Asthma, 48(8), 860-863.

Mathias, P. M., & Epstein, E. J. (2020). Iatrogenic Cushing Syndrome In An Hiv-Infected Patient Secondary to Concomitant Therapy With Genvoya and Epidural Triamcinolone. AACE Clinical Case Reports, 6(5), e217-e220.

Maviki, M., Cowley, P., & Marmery, H. (2013). Injecting epidural and intra-articular triamcinolone in HIV-positive patients on ritonavir: beware of iatrogenic Cushing’s syndrome. Skeletal radiology, 42(2), 313-315.

Neto, H. J. C., Rosário, C. S., & Rosário, N. A. (2010). Corticosteroides intranasais. Rev. bras. alerg. imunopatol, 33, 51-57.

Perry, M. E., Almaani, N., Desai, N., Larbalestier, N., Fox, J., & Chilton, D. (2013). Raltegravir-induced drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome–implications for clinical practice and patient safety. International journal of STD & AIDS, 24(8), 639-642.

Répele, C. A., Spadaro, F., Reis, M. A. D., Rodrigues, D. B. R., Ferraz, M. L. D. F., & Teixeira, V. D. P. A. (1998). Alterações morfológicas da glândula supra-renal na síndrome da imunodeficiência adquirida. Revista da Sociedade Brasileira de Medicina Tropical, 31, 257-261.

Saberi, P., Phengrasamy, T., & Nguyen, D. P. (2013). Inhaled corticosteroid use in HIV‐positive individuals taking protease inhibitors: a review of pharmacokinetics, case reports and clinical management. HIV medicine, 14(9), 519-529.

Sadarangani, S., Berg, M. L., Mauck, W., & Rizza, S. (2014). Iatrogenic cushing syndrome secondary to ritonavir-epidural triamcinolone interaction: an illustrative case and review. Interdisciplinary perspectives on infectious diseases, 2014.

Schwarze-Zander, C., Klingmüller, D., Klümper, J., Strassburg, C. P., & Rockstroh, J. K. (2013). Triamcinolone and ritonavir leading to drug-induced Cushing syndrome and adrenal suppression: description of a new case and review of the literature. Infection, 41(6), 1183-1187.

Tashkin, D. P., Lipworth, B., & Brattsand, R. (2019). Benefit: risk profile of budesonide in obstructive airways disease. Drugs, 79(16), 1757-1775.

Tiruneh, F., Awan, A., Didana, A., & Doshi, S. (2017). Preventing Cushing: iatrogenic Cushing syndrome due to ritonavir-fluticasone interaction. Cureus, 9(7).

Van Den Berg, S. A. A., van‘t Veer, N. E., Emmen, J. M. A., & Van Beek, R. H. T. (2017). Fluticasone furoate induced iatrogenic Cushing syndrome in a pediatric patient receiving anti-retroviral therapy. Endocrinology, diabetes & metabolism case reports, 2017(1).

Yoganathan, K., David, L., Williams, C., & Jones, K. (2012). Cushing's syndrome with adrenal suppression induced by inhaled budesonide due to a ritonavir drug interaction in a woman with HIV infection. International journal of STD & AIDS, 23(7), 520-521.



How to Cite

PINHEIRO, A. C. S. de O. .; ISHIGAKI, B. S. V. .; ANDRADE, M. C. S. .; RODRIGUES, A. C. B. .; FREITAS, M. L. da C. .; SASTRE, G. de S. .; CARDOSO, S. J. G. P. .; CORRÊA, B. M. P. .; BORGES, J. L. F. .; CARDOSO, A. L. C. .; HIROSE, T. S. . Iatrogenic Cushing syndrome in HIV patients: analysis of the pharmacological interaction between steroids and ritonavir. Research, Society and Development, [S. l.], v. 10, n. 17, p. e34101723547, 2021. DOI: 10.33448/rsd-v10i17.23547. Disponível em: https://rsdjournal.org/index.php/rsd/article/view/23547. Acesso em: 24 jan. 2022.



Health Sciences