Revamped HIV Guidelines Focus on Drug–Drug Interactions

Marcia Frellick

November 13, 2019

BASEL, Switzerland — Updated guidelines from the European AIDS Clinical Society (EACS) suggest dual therapy with dolutegravir and lamivudine as an alternative option to triple therapy for the initial treatment of HIV.

The evidence-based guidelines, which focus on drug–drug interactions in response to the aging of the HIV population, were presented during a news conference here at the EACS Conference 2019.

The update is "a major revision," said Manuel Battegay, MD, from the University Hospital of Basel in Switzerland, who is cochair of the conference. "I believe we are the first to say in our guidelines that initial treatment can be a dual-therapy treatment with an integrase inhibitor."

This is also the first year the guidelines have included a drug–drug interaction section, said Lene Ryom, MD, PhD, from CHIP–Rigshospitalet in Copenhagen, who served as guidelines coordinator.

The approach in the guidelines is holistic, looking at the HIV patient and not just the disease, she emphasized.

A new table guides prescribing for elderly people with HIV, and another identifies the top 10 drug classes to avoid, such as first-generation antihistamines and benzodiazepines, Ryom reported.

When it comes to benzodiazepines, the guidelines note that elderly people "are more sensitive to their effect, risk of falls, fractures, delirium, cognitive impairment, and drug dependency." The recommendation is to "use with caution, at the lowest dose and for a short duration." This is followed by suggested alternatives, which include nonpharmacologic treatment for sleep disturbance.

Aging Population

Each of the guidelines this year includes separate age-relevant guidance in recognition of the aging HIV population, said Patrick "Paddy" Mallon, MD, PhD, from University College Dublin, who served as chair of the section on comorbidities.

"We also introduced new sections on frailty and on obesity and weight gain," he reported. "These are areas where there is evolving evidence, so this is the first approach by EACS on these issues; we expect the guidance will evolve."

An aging population means we have to look beyond interactions between HIV and non-HIV drugs, said Catia Marzolini, PharmD, PhD, from University Hospital Basel.

For example, a common issue is that the doses of drugs prescribed to elderly people are not being adjusted to account for the renal function of the patient, she explained. A new table lists drugs commonly prescribed to older patients that should be dosed in accordance with renal function.

With the aging population, issues like these have become "a daily discussion," said Battegay.

"For instance, we have an extended table that details which pills can be crushed, which is particularly helpful if a patient is in intensive care, perhaps on ventilation, and you need to know which drugs can be given by feeding tube," he explained.

Other tables let a physician see the optimal drugs for an HIV patient who has hypertension, lipid elevation, or gaps in vaccine schedules.

This is the first time the EACS guidelines are available in several formats: an interactive website, in book form, and through an app. The online and app versions offer links to short videos that expand on individual guidelines, such as when to start antiretroviral therapy, when to change it, and explanations of adverse effects.

Clinicians can use the interactive website to show patients information on a larger screen, highlight sections, and transfer supporting guidelines into their reporting systems.

The online version of the EACS guidelines will be revised annually. The print version will revised every 2 years, but interim updates on essential information will be incorporated in real time.

European AIDS Conference (EACS) 2019. Presented November 7, 2019.

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