Hepatic enzyme inhibitors: protease inhibitors (including ritonavir) or ketoconazole may decrease corticosteroid clearance via CYP3A4 inhibition resulting in increased effects such as Cushing's syndrome and adrenal suppression. Co-administration of triamcinolone hexacetonide with CYP 3A inhibitors (including cobicistat-containing products) is not recommended unless the potential benefit of treatment outweighs the risk of systemic corticosteroid effects. If the potential benefit of co-administration outweighs the increased risk of systemic corticosteroid side-effects, patients should be monitored for these effects (see section ).
4) Because of the advantages of ADT, it may be desirable to try patients on this form of therapy who have been on daily corticoids for long periods of time (eg, patients with rheumatoid arthritis). Since these patients may already have a suppressed HPA axis, establishing them on ADT may be difficult and not always successful. However, it is recommended that regular attempts be made to change them over. It may be helpful to triple or even quadruple the daily maintenance dose and administer this every other day rather than just doubling the daily dose if difficulty is encountered. Once the patient is again controlled, an attempt should be made to reduce this dose to a minimum.