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Adrenal Disorders

(8.02) Genvoya-associated Iatrogenic Cushing's Syndrome

Friday, May 10, 2024
10:10 AM – 10:25 AM CDT
Location: ePoster Showcase, Empire Ballroom Foyer, Level 2
Introduction : Cobicistat, a pharmacological booster found in Genvoya, is a p</span>otent CYP450 inhibitor. When used concurrently with steroids, it has been associated with the accumulation of exogenous steroids in the serum and increased risk of iatrogenic Cushing’s syndrome (ICS) and concurrent hypothalamic pituitary adrenal (HPA) axis suppression.

Case(s) Description : A 70-year-old male with past medical history of HIV, new onset type 2 diabetes, and hip bursitis was seen for generalized weakness. He developed facial swelling, easy bruising, and weight gain over the past 4 months. His medications included Genvoya and intra-articular triamcinolone injections for the bursitis. Physical exam revealed fat deposition under the mandible and neck, increased filling of the supra clavicular fat pads, dorsal fat, and thin lower extremities with bruising. Laboratory tests showed a low morning cortisol of 5.9 mcg/dL and low 24-hour urine cortisol of 2 ug/24-hr. ACTH stimulation test revealed a cortisol of 1.4 mcg/dL, 10.3 mcg/dL, and 13.7 mcg/dL at 0, 30, and 60 minutes, respectively, and a low ACTH level of 6.4 pg/mL, suggesting hypothalamic pituitary adrenal (HPA) axis suppression. The p</span>atient was switched from Genvoya to Biktarvy, triamcinolone injections were discontinued, and he was started on 10 mg of oral hydrocortisone in the morning, and 5 mg in the afternoon. 5 months later the patient reported improved weakness and facial swelling. In addition, his p</span>hysical exam and laboratory tests returned to normal, and hydrocortisone was subsequently tapered. 

Discussion : The most common cause of ICS is oral steroid treatment; however, it has been associated with injected, topical, and inhaled glucocorticoids. Potent CYP450 inhibitors like cobicistat, a component of Genvoya, have been associated with the development of ICS and concomitant adrenal insufficiency by suppression of the HPA axis. Clinicians should be aware that co-administration of CYP450 inhibiting medications with exogenous corticosteroid, regardless of modality of exposure, can increase the likelihood of systemic adverse effects like ICS with adrenal insufficiency.