geoffrey modest medical blogs

    In patients with difficult-to-control type II diabetes, an impressive study found that about one quarter of them have hypercortisolism, and mifepristone improves their hyperglycemia (see dm hypercortisolism DiabCar2025  in dropbox or https://doi.org/10.2337/dc24-2841 ). thanks to Dr Elvira Isganaitis for bringing this to my attention.   Details : -- the CATALYST study enrolled 1063 participants with type II diabetes and a hemoglobin A1c ranging from 7.5%-11.5% and who were on two or more glucose lowering medications with or without micro/macro vascular complications or taking multiple blood pressure lowering medications -- these patients were screened with a 1 mg dexamethasone suppression test (DST)     -- common causes of false positives in DST evaluations were excluded, including taking oral contraceptives, excessive alcohol consumption, severe untreated sleep apnea, severe psych/medical/surgical illness, night shift work or hemodia...

Jason Worcester at bmc brought up concerns about steroid injections in patients on certain HIV drugs.  i sent out an email/blog 5 years ago on the potentially very severe consequences of topical steroids (inhalation, joint injection) in patients on ritonavir .  a recent search found some similar issues with cobicistat, also a profound cytochrome P450 3A (CYP3A) i nhibitor, now used in some HIV cocktails. so, given the rather frequent prescriptions for inhaled steroids (esp fluticasone) and injected steroids into joints/bursae/trigger points, i thought it would be useful to resend and expand the prior blog (which is appended below) --a case report of iatrogenic adrenal suppression after using inhaled intranasal fluticasone and cobicistat (in the combo evitegravir, cobicistat, emtricatibine, tenofovir = stribild). see  hiv cobicistat cushing ClinMed2016 in dropbox, or Elliot ER. Clinical Medicine. 2016; 16: 412 --and another cas...

the issue recently came up in terms of adverse effects (ie, iatrogenic cushings) in patients on hiv cocktail containing ritonivir and use of even local steroids (the issue being that ritonivir is an extremely potent inhibitor of CYP 3A4 , leading to excessive increases in circulating levels of drugs metabolized through this system). i brought up this question with HIV providers in san francisco (the HIV consult line) and received the following answer: 1. lots of problems with inhaled steroids, esp fluticasone and budesonide. better results with beclomethasone, nasolide and flunisolide (i asked them is that just because fluticasone and budesonide are used more frequently, esp since prior studies have found that these 2 drugs in particular have the highest tissue-to-blood levels -- and they did not know, but said that the medical literature is replete with examples of cushings in using these drugs. of note, a drug company study did find a 350-fold increase of seru...