Antifungals and Acute Illness

Patients on chronic antifungal treatment for fungal infections, like those of the foot, are at increased risk of secondary adrenal insufficiency when acutely ill. Remembering that ketoconazole is sometimes used as a treatement for high cortisol levels by inhibiting the P450 system and impeding cortisol production, it makes sense that the production of cortisol can also be decreased in patients who had previously had normal cortisol levels. This does not really cause much of a problem on a daily basis with these patients, but if the patient becomes acutely ill and is hospitalized, you might want to consider a bit of steroid replacement while they get over their acute illness. Especially consider this if the patient has refractory hyponatremia, hypoglycemia, or hypotension.