Polypharmacy and HIV
With the availability of effective antiretroviral therapy (ART), people living with HIV are increasingly managing long-term HIV infection and other age-related illnesses, such as cardiovascular disease, diabetes, chronic kidney disease, osteoporosis, and non-AIDS malignancies.1 People living with HIV may also have earlier onset of age-related comorbidity than uninfected individuals due to chronic immune activation, lifestyle factors such as drug or alcohol use, viral co-infections like hepatitis, and/or toxicities of certain ART.2
Complex comorbidity may result in polypharmacy, defined as the prescription of medications for multiple underlying disease states, or sometimes as a threshold number of active prescriptions—such as the concurrent administration of 5 or more medications.2 In HIV medicine, polypharmacy often refers to non-HIV medications or co-medications given in addition to ART.
By 2030, it's estimated that1:
73%of people living with HIV will be aged 50 years or older
28%will have 3 or more age-related comorbidities
20%will be prescribed 3 or more co-medications
When prescribing or switching drugs in an antiretroviral (ARV) regimen, conducting a thorough review of concomitant medications with an expert in ARV pharmacology can help minimize adverse drug interactions.3 When drugs with competing metabolic pathways are prescribed together, drug interactions can be especially difficult to predict, and close monitoring for therapeutic efficacy or toxicities is recommended. See more information on drug-drug interactions (DDIs).
Polypharmacy in HIV has been associated with an increased risk of DDIs and other adverse health effects, including1,2,4:
Adherence problems resulting from high pill burden
Adverse drug reactions involving medications with overlapping side effects
Loss of treatment efficacy and subsequent virologic breakthrough
Physical decline, cognitive impairment, hospitalization, and mortality
Increased healthcare costs for the patient and healthcare system
To help address the challenges of polypharmacy and HIV, primary care providers are encouraged to perform a medication review at every visit along with a complete medication reconciliation annually to ensure an active medication list is available.5 These steps help determine when medications are no longer clinically indicated and may be discontinued to reduce the risk of toxicity, adverse effects, and drug-drug interactions. Documenting a current list of patients’ active medications can also help inform care if they are seen in specialty clinics or require hospitalization.
If possible, patients should also be encouraged to use a single pharmacy, preferably one specialized in caring for people living with HIV and with an integrated network connected to the patient’s electronic medical record.5 Utilizing a specialty pharmacy has been associated with improved HIV care, with benefits including: fewer contraindicated medications; improved medication adherence; and improved pharmacist-prescriber communication regarding DDIs, medication reconciliation, monitoring adherence, and providing adherence aids.
References:
1. Smit M, Brinkman K, Geerlings S, et al. Future challenges for clinical care of an ageing population infected with HIV: a modelling study. Lancet Inf Dis. 2015;15:810-18.
2. Back D and Marzolini C. The challenge of HIV treatment in an era of polypharmacy. J Int AIDS Soc. 2020;23:e25449.
3. Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in adults and adolescents with HIV. Department of Health and Human Services. http://aidsinfo.nih.gov/contentfiles/lvguidelines/AdultandAdolescentGL.pdf. Updated December 18, 2019. Accessed August 3, 2020.
4. McGrath K, Hajjar ER, Kumar C, et al. Deprescribing: a simple method for reducing polypharmacy. J Fam Pract. 2017;66(7):436-445.
5. Drug-drug interactions and polypharmacy in HIV and aging. The American Academy of HIV Medicine website. https://aahivm-education.org/hiv-age/chapter-13/ddi-polypharmacy. Updated February 3, 2020. Accessed August 3, 2020.
HVUWCNT200008 September 2020
