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JAC Advance Access originally published online on August 4, 2009
Journal of Antimicrobial Chemotherapy 2009 64(4):850-852; doi:10.1093/jac/dkp280
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© The Author 2009. Published by Oxford University Press on behalf of the British Society for Antimicrobial Chemotherapy. All rights reserved. For Permissions, please e-mail: journals.permissions@oxfordjournals.org

Original research

Influence of concomitant prednisolone on trimethoprim-associated hyperkalaemia

Sumit Mohan*, Manasvi Jaitly, Velvie A. Pogue and Jen-Tse Cheng

Columbia University College of Physicians and Surgeons, Department of Medicine, Division of Nephrology, Harlem Hospital Center, 506 Lenox Avenue, New York, NY 10037, USA

Received 13 November 2008; returned 17 January 2009; revised 6 July 2009; accepted 9 July 2009

* Corresponding author. Tel: +1-212 939 1448; Fax: +1-212 939 1745; E-mail: sm2206{at}columbia.edu

Objectives: Trimethoprim–sulfamethoxazole may cause hyperkalaemia by the amiloride-like effect of trimethoprim on sodium channels in the distal nephron. Hyperkalaemia usually occurs after 7–10 days and has been reported in 20%–50% of patients receiving trimethoprim–sulfamethoxazole. Patients with Pneumocystis jiroveci pneumonia and severe hypoxaemia benefit from the use of prednisolone as an adjuvant to trimethoprim–sulfamethoxazole. The addition of prednisolone may lower the incidence of trimethoprim-related hyperkalaemia due, in part, to its mineralocorticoid activity. We studied the effect of concomitant prednisolone on trimethoprim-related hyperkalaemia.

Patients: Thirty patients qualified for inclusion and were reviewed. Patients were divided into two groups: one group received trimethoprim–sulfamethoxazole plus prednisolone (18 patients); and the other group received trimethoprim–sulfamethoxazole alone (12 patients).

Results: The two groups were comparable at baseline, except for the severity of the P. jiroveci pneumonia. Hyperkalaemia developed in seven patients: all in the prednisolone and trimethoprim–sulfamethoxazole group. The greater incidence of hyperkalaemia in this group is surprising and was counter to our expectation.

Conclusions: Although it is possible that there is an unexplained interaction between trimethoprim and prednisolone, we postulate that our observation is a result of the catabolic effect of prednisolone. The patients treated with trimethoprim–sulfamethoxazole plus prednisolone appear to be more likely to develop hyperkalaemia than patients treated with trimethoprim–sulfamethoxazole alone.

Keywords: Pneumocystis pneumonia , HIV , prednisone , glucocorticoid , mineralocorticoid


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