Fluticasone Interactions
- Atazanavir
- Delavirdine
- Isoproterenol
- Ketoconazole
- Mecasermin, Recombinant, rh-IGF-1
- Nelfinavir
- Ritonavir
Toxoids
Vaccines
Fluticasone Interactions
No drug interactions have been reported with topical fluticasone cream or ointment.
Caution is warranted when ketoconazole or other very potent cytochrome P-450 3A4 inhibitors are prescribed with oral fluticasone inhalations; patients may need to be observed for increased corticosteroid-related side effects. Ketoconazole, when added to an existing fluticasone oral inhalation regimen, resulted in increased fluticasone concentrations and reduced plasma cortisol AUC, but had no effect on urinary excretion of cortisol. Erythromycin did not affect fluticasone’s pharmacokinetics in a different study. Due to the very low concentrations achieved after intranasal dosing, clinically significant interactions between intranasal fluticasone and potent CYP3A4 inhibitors are unlikely.
The risk of cardiac toxicity with isoproterenol in asthma patients appears to be increased with the coadministration of corticosteroids or methylxanthines. Intravenous infusions of isoproterenol in refractory asthmatic children at rates of 0.05 - 2.7 mcg/kg/min have caused clinical deterioration, myocardial infarction (necrosis), congestive heart failure and death.
Killed or inactivated vaccines and toxoids do not represent a danger to immunocompromised persons and generally should be administered as recommended for healthy persons. The immune response of immunocompromised persons to vaccines is not as good as healthy persons; higher doses or more frequent boosters may be required, although the immune response still may be suboptimal. Live-virus vaccines should not be given to immunocompromised individuals due to the potentiation of virus replication and adverse reactions to the virus. Those undergoing high-dose corticosteroid therapy should not be exposed to others who have recently received the oral poliovirus vaccine (OPV). Measles-mumps-rubella (MMR) vaccination is not contraindicated for the close contacts, including health care professionals, of immunocompromised patients. Passive immunoprophylaxis with immune globulins may be indicated for immunocompromised persons instead of, or in addition to, vaccination. When exposed to a vaccine-preventable disease such as measles, severely immunocompromised children should be considered susceptible regardless of their vaccination history.
Via inhibition of CYP3A4, ritonavir significantly increases plasma fluticasone exposure, resulting in significantly reduced serum cortisol concentrations. During post-marketing use, there have been reports of clinically significant drug interactions in patients receiving inhaled or intranasally administered fluticasone with ritonavir, resulting in systemic corticosteroid effects including Cushing syndrome and adrenal suppression. Therefore, coadministration of fluticasone (or fluticasone-containing products) and ritonavir (or ritonavir-containing products or treatment regimens) is not recommended unless the potential benefit to the patient outweighs the risk of systemic corticosteroid side effects.
Atazanavir is typically prescribed (i.e., ‘boosted’) with low-dose ritonavir. The concomitant use of atazanavir and ritonavir with fluticasone may increase fluticasone concentrations, due to ritonavir’s inhibition of fluticasone metabolism, resulting in significantly reduced plasma cortisol concentrations. The coadministration of fluticasone (by oral or intranasal inhalation) with atazanavir and ritonavir is not recommended unless the potential benefits outweigh the risks of systemic corticosteroid side effects (i.e., Cushing’s syndrome and adrenal suppression). Additionally, atazanavir itself may increase fluticasone concentrations. Atazanavir and fluticasone should be coadministered cautiously, and another corticosteroid should be considered if long-term corticosteroid treatment is necessary.
Nelfinavir may inhibit CYP3A4 metabolism of fluticasone, resulting in increased plasma fluticasone concentrations and reduced serum cortisol concentrations. During post-marketing use, there have been reports of clinically significant drug interactions in patients receiving inhaled or intranasally administered fluticasone with ritonavir, resulting in systemic corticosteroid effects including Cushing syndrome and adrenal suppression. Similar results are expected with nelfinavir. Consider using an alternative treatment to fluticasone, particularly if long term use is indicated.
Additional monitoring may be required when coadministering systemic or inhaled corticosteroids with mecasermin, recombinant, rh-IGF-1. In animal studies, corticosteroids impair the growth-stimulating effects of growth hormone (GH) through interference with the physiological stimulation of epiphyseal chondrocyte proliferation exerted by GH and IGF-1. Dexamethasone administration on long bone tissue in vitro resulted in a decrease of local synthesis of IGF-1. Similar counteractive effects are expected in humans. If systemic or inhaled glucocorticoid therapy is required, the steroid dose should be carefully adjusted and growth rate monitored.
Delavirdine may inhibit CYP3A4 metabolism of fluticasone, resulting in increased plasma fluticasone concentrations and reduced serum cortisol concentrations. During post-marketing use, there have been reports of clinically significant drug interactions in patients receiving inhaled or intranasally administered fluticasone with ritonavir, resulting in systemic corticosteroid effects including Cushing syndrome and adrenal suppression. Similar results are expected with delavirdine. Consider using an alternative treatment to fluticasone, particularly if long term use is indicated.
[ Last revised: 4/21/2006 1:50:00 PM ]
References
. US Department of Health and Human Services (DHHS) and National Institutes of Health (NIH). The Living Document: Guidelines for the use of antiretroviral agents in HIV-infected adults and adolescents. Retrieved May 5, 2006. Available on the World Wide Web at http://www.aidsinfo.nih.gov.
. Centers for Disease Control and Prevention (CDC). General recommendations on immunization: Recommendations of the Advisory Committee on Immunization Practices (ACIP) and the American Academy of Family Physicians (AAFP). MMWR 2002;51(RR-2):1 - 36.
. Isuprel® (isoproterenol) package insert. Chicago, IL: Abbott Laboratories; 1989.
. Reyataz™ (atazanavir) package insert. Princeton, NJ: Bristol-Myers Squibb Company; 2006 Jan.
. Norvir® (Ritonavir) package insert. Chicago, IL: Abbott Laboratories; 2005 Nov.
. Kaletra® (lopinavir, ritonavir) package insert. Chicago, IL: Abbott Laboratories; 2005 Oct.
. Flovent® (fluticasone) package insert. Research Triangle Park, NC: GlaxoSmithKline; 2004 Apr.
. Rescriptor® (delavirdine) package insert. La Jolla, CA: Agouron Pharmaceuticals; 2001 Nov.
. Viracept® (nelfinavir mesylate) package insert. La Jolla, CA: Agouron Pharmaceuticals, Inc.; 2005 Aug.
. Jux C, Leiber K, Hugel U, et al. Dexamethasone impairs growth hormone (GH)-stimulated growth by suppression of local insulin-like growth factor (IGF)-1 production and expression of GH- and IGF-1 receptor in cultured rat chondrocytes. Endocrinology 1998;139:3296 - 305.
. Allen DB. Inhaled corticosteroid therapy for asthma in preschool children: growth issues. Pediatrics 2002;109:373 - 80.
Related entries
Monthly Archives
Syndicate
Allergies
