Challenges with polypharmacy in the aging HIV patient
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The proportion of people living with HIV (PLWH) who are older than age 50 years is increasing, such that in 2018, approximately 50% of PLWH fell into this category.
This is primarily due to the development of potent ART that effectively suppresses patients’ viral load to undetectable levels. The life expectancy of PLWH is now comparable to that of the general population.
There are a couple of main concerns regarding the management of HIV in an aging population. First, patients are now living long enough to develop chronic age-related comorbidities, such as heart disease, kidney disease, diabetes, chronic pulmonary disease and other chronic health-related issues. Inevitably, these comorbid conditions result in the need for additional medications that can complicate treatment. Drug-drug interactions, increased adverse effects and possible reduced compliance with ART are all potential complications as the pill burden increases. Secondly, there are physiologic changes that can affect the pharmacokinetics of the drugs we use to treat HIV infection. As we age, body fat increases and there is a decrease in free water and a decline in renal and hepatic function, which all can have a significant impact on the pharmacokinetics of our therapies.
Polypharmacy is the use of five or more medications and is an important public health issue facing older adults. It is more common among PLWH than the general population. Among PLWH, the prevalence of polypharmacy increases with age as well as with duration of HIV infection.
In a French study, 62% of people diagnosed with HIV before 2000 had at least one comorbidity, and 71% of those were taking at least one medication in addition to their ART. Polypharmacy has been associated with increased morbidity, mortality, falls, hospitalizations and other adverse events. As a result, research is ongoing to assess how to reduce the number of medications our patients are taking.
Drug-drug interactions common
A pharmacist-led program screened PLWH who were aged 50 years or older in a large urban clinic using the Beers Criteria and an instrument called the Screening Tool of Older Persons’ Potentially Inappropriate Prescriptions to assess potentially inappropriate prescribing. In this study, they found that the mean number of chronic medications these patients were taking was 14, and when excluding antiretrovirals, the mean was 11. This would suggest that the main driver of polypharmacy among older patients is medication use for comorbidities.
After pharmacy screening, at least one medication was discontinued for 69% of patients, whereas 10% had six or more medications discontinued. Although this was an effective strategy for identifying problematic medication-related issues, it was a resource-intensive process. Each visit to reconcile and evaluate the patient’s medications took about 45 minutes to complete, which would make it difficult to incorporate into a busy clinic with limited resources.
Another study evaluated the prevalence of polypharmacy and drug-drug interactions among individuals enrolled at two centers in the Swiss HIV Cohort Study. Patients documented their current medications, including over-the-counter agents before their biannual visit. The Beers Criteria were used to evaluate for potentially inappropriate medications, while drug-drug interactions were screened using the Liverpool drug interaction database.
Consistent with other studies, polypharmacy was more common among patients aged 65 years or older compared with younger patients (44% vs. 12%). Potential drug-drug interactions with cardiovascular-related medications were more common among elderly patients, whereas central nervous system-related agents were more common among younger patients. Although the use of unboosted integrase inhibitors was common among both younger and older patients, one-third of patients in the study required complex ART regimens that were prone to drug-drug interactions.
Interestingly, no deleterious consequences were detected in this study because physicians had properly adjusted dosages to account for these interactions. In addition, potentially inappropriate medications were found for 31% of elderly patients — mostly benzodiazepines and hypnotics, which can lead to an increased risk of falls, confusion and hospitalizations in older patients.
In a retrospective analysis of 89 patients enrolled in the University of California, San Francisco HIV Over 60 Cohort study, researchers evaluated inappropriate medications defined by modified Beers Criteria and the Anticholinergic Risk Scale, and for drug-drug interactions. The median age of patients was 64 years (range 60 to 82). Participants took a median of 13 medications, the majority of which were non-ART.
Medication-related problems were common, with 70% having at least one drug-drug interaction and 52% having at least one potentially inappropriate medication. Importantly, when compared with age- and gender-matched HIV-uninfected participants, these medication-related problems were higher in the HIV-infected group.
Much work needed
There are several issues that need to be addressed regarding polypharmacy among PLWH. Obtaining a complete medication reconciliation, including any over-the-counter agents and assessing their need on every patient visit, is needed to help identify potential drug-drug interactions, as well as the potential for additive adverse events. It’s also important to set a goal for therapy and monitoring strategy when a new medication is prescribed. The patient should be educated regarding the importance of being compliant with the prescribed medications, along with what to be aware of if serious adverse events occur.
In addition, it is clear that ensuring safe and effective therapy for older PLWH relies on a multidisciplinary team to screen and monitor for potential problems. Pharmacist-led evaluation strategies appear to be effective in identifying potential drug-related issues and promoting safe prescribing practices. However, much work is still needed in this area. In the meantime, focusing on prevention of chronic health conditions through nonpharmacologic mechanisms such as exercise, smoking cessation, reduction of substance abuse and promotion of proper nutrition may help alleviate comorbid conditions that require additional medication treatment.
- References:
- CDC. HIV surveillance report. http://www.cdc.gov/hiv/library/reports/hiv-surveillance.html. Accessed Feb. 13, 2022.
- Courlet P, et al. Open Forum Infect Dis. 2019;doi:10.1093/ofid/ofz531.
- Cuzin L, et al. HIV Med. 2017;doi:10.1111/hiv.12441.
- Edelman EJ, et al. Curr Opin HIV AIDS. 2020;doi:10.1097/COH.0000000000000608.
- Greene M, et al. J Am Geriatr Soc. 2014;doi:10.1111/jgs.12695.
- HIV.gov. Guidelines for the use of antiretroviral agents in adults and adolescents living with HIV. https://clinicalinfo.hiv.gov/en/guidelines/adult-and-adolescent-arv. Updated Jan. 20, 2022. Accessed Feb. 13, 2022.
- Kamkwalala AR, et al. AIDS Res Hum Retroviruses. 2021;doi: 10.1089/aid.2021.0059.
- McNicholl IR, et al. Pharmacotherapy. 2017;doi:10.1002/pharm.2043.
- For more information:
- Jeff Brock, PharmD, MBA, BCPS AQ-ID, is an Infectious Disease News Editorial Board Member and an infectious disease pharmacy specialist at Mercy Medical Center in Des Moines, Iowa. He can be reached at: jbrock@mercydesmoines.org.
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