Background: The frequency of hypothalamic-pituitary-adrenal axis dysfunction among HIV-infected patients receiving steroid injections has not been reported, and the risk factors for this adverse event are poorly characterized.
Methods: We conducted a retrospective analysis of data from HIV-infected patients in the Partners HealthCare system (Boston, MA) who received corticosteroid injection(s) between 2002 and 2011. Chart review focused on HIV status, antiretroviral therapy [eg, protease inhibitors (PI)], steroid injection(s), and adrenal axis dysfunction (eg, adrenal insufficiency and/or Cushing syndrome). Because all cases occurred among patients on PIs, we performed additional detailed data extraction and conducted univariate and multivariate analyses to identify risk factors in this group.
Results: One hundred seventy-one HIV-infected patients received ≥1 corticosteroid injection(s) in the study period. Nine cases (event frequency: 5.3%; 95% confidence interval: 2.4% to 9.8%) of secondary adrenal insufficiency were diagnosed; 5 (55%) of these 9 patients also had clinical evidence of Cushing syndrome. All cases occurred among the 81 patients on PIs (event frequency among those on PIs: 11.1%; 95% confidence interval: 5.2% to 20.0%). Among patients on PIs, the major risk factor for hypothalamic-pituitary-adrenal axis dysfunction was having ≥2 injections within 6 months.
Conclusions: In this retrospective cohort study, 11% of HIV-infected patients on PIs at the time of steroid injection were later diagnosed with hypothalamic-pituitary-adrenal axis dysfunction. Corticosteroid injections in HIV-infected patients on PIs should only be used with great caution and close monitoring.
*Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA;
†Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA;
‡Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA;
§Division of Infectious Diseases, Brigham and Women’s Hospital, Boston, MA;
‖Department of Pharmacy, Massachusetts General Hospital, Boston, MA;
¶Research Design Center/Biostatistics Research Center, Clinical and Translational Science Institute, Tufts University, Boston, MA;
#Division of Endocrinology, Yale University School of Medicine, New Haven, CT;
**Division of Endocrinology, Massachusetts General Hospital, Boston, MA;
††Department of Newborn Medicine, Brigham and Women's Hospital, Boston, MA;
‡‡Harvard University Center for AIDS Research, Boston, MA;
§§Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, MA; and
‖‖Ragon Institute of Massachusetts General Hospital, MIT and Harvard, Charlestown, MA.
Correspondence to: Emily P. Hyle, MD, Division of Infectious Diseases, Massachusetts General Hospital, 50 Staniford Street, 9th Floor, Boston, MA 02114-2696 (e-mail: email@example.com).
E.P.H. is supported by National Institute of Allergy and Infectious Disease [T32 AI 007433]. R.T.G. is supported by National Institutes of Health (NIH) [R01 AI066992-04A1] and NIH G08LM008830-01 and by grants to the AIDS Clinical Trials Group (NIH U01 AI 694722) and the Harvard University Center for AIDS Research (NIH 2P30 AI060354-06). This publication was made possible with help from the Harvard University Center for AIDS Research (CFAR), an NIH-funded program (P30 AI060354), which is supported by the following NIH co-funding and participating institutes and centers: NIAID, NCI, NICHD, NHLBI, NIDA, NIMH, NIA, FIC, and OAR.
R.T.G. has received grant support from Tibotec (now Janssen), Abbott, and Viiv.
Received February 20, 2013
Accepted May 09, 2013