Cushing's syndrome in an 81-year-old patient treated with budesonide and amiodarone

CLInical Profile and Side Effects of chronic use of oral Amiodarone in cardiology outpatients department (CLIPSE-A Study)- A prospective observational study

Background

Amiodarone belongs to Class-III anti-arrhythmic drugs. It is one of the most effective anti-arrhythmic drugs used to treat or prevent several types of arrhythmias including atrial fibrillation, atrial flutter, ventricular tachycardia, and wide complex tachycardia, but unfortunately carries a high toxicity profile. Also, side effects of amiodarone involving various organs can be life-threatening.

Materials & methods

This was an observational study carried out for six months i.e from April to September. The study included patients who are on amiodarone for greater than or equal to six months. The required data was collected in-person from the case sheets, treatment charts, and by interviewing the patients. The data for 67 patients was documented in suitable data collection form for analysis.

Results

From our study data, it was noted that amiodarone was used for 3 different indications-atrial fibrillation, atrial flutter, and ventricular tachycardia. Among 67 patients enrolled, 38 had no side-effects. Side-effects data in the rest grouped basing on the organ system affected: 9 patients had renal effects, 6 patients had ophthalmic effects, 4 patients had endocrine effects, and 5 patients had hepatic effects.

Conclusion

From our study, it is concluded that amiodarone is a safe and effective anti-arrhythmic drug at lower doses i.e. 200-1100 mg/week. When treated in lower doses of 1400–2800 mg/week, many side effects have been incident. Although these effects are mild and develop only after prolonged usage of the drug, it should be used judiciously.

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Amiodarone has an unusual spectrum of side effects with a prevalence of 15% in the first year, increasing up to 50% during long-term use.

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Our study demonstrated amiodarone does not produce significant side-effects when used in doses of 200–1100 mg/week.

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Few side-effects are observed when amiodarone is used in higher doses of 1200–2800 mg/week.

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When a side-effect is observed, mere reducing the dose or withdrawal of drug might help.

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In most of the cases of atrial fibrillation, amiodarone is discontinued or altered in first year of treatment basing on risk/benefit ratio.

Complex Drug-Drug-Gene-Disease Interactions Involving Cytochromes P450: Systematic Review of Published Case Reports and Clinical Perspectives

Drug pharmacokinetics (PK) is influenced by multiple intrinsic and extrinsic factors, among which concomitant medications are responsible for drug-drug interactions (DDIs) that may have a clinical relevance, resulting in adverse drug reactions or reduced efficacy. The addition of intrinsic factors affecting cytochromes P450 (CYPs) activity and/or expression, such as genetic polymorphisms and diseases, may potentiate the impact and clinical relevance of DDIs. In addition, greater variability in drug levels and exposures has been observed when such intrinsic factors are present in addition to concomitant medications perpetrating DDIs. This variability results in poor predictability of DDIs and potentially dramatic clinical consequences. The present review illustrates the issue of complex DDIs using systematically searched published case reports of DDIs involving genetic polymorphisms, renal impairment, cirrhosis, and/or inflammation. Current knowledge on the impact of each of these factors on drug exposure and DDIs is summarized and future perspectives for the management of such complex DDIs in clinical practice are discussed, including the use of advanced Computerized Physician Order Entry (CPOE) systems, the development of model-based dose optimization strategies, and the education of healthcare professionals with respect to personalized medicine.

Iatrogenic Cushing's syndrome related to the interaction between oral budesonide with fluvoxamine: a case report

WHAT IS KNOWN AND OBJECTIVE

Budesonide, an oral glucocorticoid indicated for the treatment of Crohn's disease, rarely interferes with the hypothalamic-pituitary-adrenal axis because more than 80% of it is metabolized by cytochrome P450 enzymes.

CASE SUMMARY

A 33-year-old female patient diagnosed with Crohn's disease, treated with oral budesonide, was admitted for Cushingoid symptoms and signs. The onset coincided with the use of fluvoxamine, a serotonin reuptake inhibitor and also a potent inhibitor of cytochrome P450 enzymes that presumably led to budesonide accumulation.

WHAT IS NEW AND CONCLUSION

Practitioners should take into consideration the possibility of iatrogenic Cushing's syndrome caused by the association of oral budesonide with a P450 cytochrome inhibitor.

Drug-induced endocrine disorders in the intensive care unit

The neuroendocrine response to critical illness is key to the maintenance of homeostasis. Many of the drugs administered routinely in the intensive care unit significantly impact the neuroendocrine system. These agents can disrupt the hypothalamic-pituitary-adrenal axis, cause thyroid abnormalities, and result in dysglycemia. Herein, we review major drug-induced endocrine disorders and highlight some of the controversies that remain in this area. We also discuss some of the more rare drug-induced syndromes that have been described in the intensive care unit. Drugs that may result in an intensive care unit admission secondary to an endocrine-related adverse event are also included. Unfortunately, very few studies have systematically addressed drug-induced endocrine disorders in the critically ill. Timely identification and appropriate management of drug-induced endocrine adverse events may potentially improve outcomes in the critically ill. However, more research is needed to fully understand the impact of medications on endocrine function in the intensive care unit.

Nonabsorbable corticosteroids use in the treatment of gastrointestinal graft-versus-host disease

For over a decade, nonabsorbable corticosteroids have been employed in the treatment of gastrointestinal graft-versus-host-disease (GVHD) in hematopoietic stem cell transplant (HSCT), as monotherapy or in combination with systemic corticosteroids. The majority of the evidence showing a favorable outcome consisted of case series, small phase II trials and a large randomized phase III trial. The 2 most commonly studied molecules were oral budesonide and beclomethasone diproprionate. Although these reports hint at some benefit with the local treatment strategy, their methodologic inconsistencies preclude meaningful adoption to everyday clinical practice. This review evaluates the current evidence of nonabsorbable corticosteroids in HSCT and sets forth recommendations for future trials with these agents.

Oral Budesonide in the Management of Crohn's Disease

OBJECTIVE

To review the pharmacology, pharmacokinetics, efficacy, and safety of oral budesonide (Entocort EC) in the treatment of mild to moderate Crohn's disease (CD).

DATA SOURCES

The MEDLINE database (1966-December 2002) was searched using the key words budesonide and inflammatory bowel diseases and restricted to the English language. The references from relevant articles were also reviewed for additional citations.

STUDY SELECTION AND DATA EXTRACTION

Articles and abstracts that evaluated oral budesonide for management of CD were considered, with emphasis on randomized, controlled clinical trials.

DATA SYNTHESIS

Budesonide's high potency at the glucocorticoid receptor and extensive first-pass hepatic metabolism result in a topical antiinflammatory effect on intestinal tissue, with minimal systemic glucocorticoid adverse effects. Clinical trials have demonstrated that budesonide is effective in the treatment of patients with mild to moderate CD of the ileum and ascending colon, with efficacy similar to prednisolone and superior to mesalamine. Long-term therapy with budesonide increased the duration of CD remission, but the effect was not sustained up to 1 year. Budesonide failed to prevent postsurgical relapse of CD. Adrenal suppression and glucocorticoid-related adverse effects have been reported at lower rates in patients treated with budesonide compared with prednisolone. Patients prescribed budesonide should be monitored for hepatic dysfunction and potential drug interactions.

CONCLUSIONS

Budesonide is an effective and relatively safe option for treatment of mild to moderate CD of the ileum and ascending colon.

Diagnosis and differential diagnosis of Cushing's syndrome

The clinical recognition of Cushing's syndrome and its biochemical confirmation is a challenging problem. The best diagnostic approach to patients with suspected Cushing's syndrome is still evolving. The traditional diagnostic approach of urine free cortisol and low-dose dexamethasone suppression testing may be inadequate when the degree of hypercortisolism is mild. Late-night salivary cortisol determinations may evolve as the simplest means of screening patients for suspected hypercortisolism. Repeated measurements of cortisol secretion (urine free cortisol or late-night salivary cortisol) over an extended period of time may be necessary to provide diagnostic certainty. The dexamethasone-CRH test is a reasonable approach in patients with equivocal data. The introduction of reliable, sensitive, and specific plasma ACTH measurements, the use of IPSS for ACTH with CRH stimulation, and the improved techniques of pituitary and adrenal imaging have made the differential diagnosis of Cushing's syndrome relatively straightforward (see Fig. 2). Clinicians who have never missed the diagnosis of Cushing's syndrome or have never been fooled by attempting to establish its cause should refer their patients with suspected hypercortisolism to someone who has.