Potentially Inappropriate Medications in Older Adults Living With HIV

B López-Centeno; C Badenes-Olmedo; A Mataix-Sanjuan; JM Bellón; L Pérez-Latorre; JC López; J Benedí; S Khoo; C Marzolini; MJ Calvo-Alcántara; J Berenguer

Disclosures

HIV Medicine. 2020;21(8):541-546. 

In This Article

Discussion

In this population-based study of 1292 older PLWH, two-thirds of whom experienced polypharmacy, a PIM according to the 2019 AGS Beers criteria was identified in 37% of study participants. Benzodiazepines and NSAIDs were the most common inappropriate drugs prescribed, and female sex and polypharmacy increased the risk of having a PIM.

Inappropriate prescribing is frequent in older individuals, including older PLWH, and has been associated with adverse health outcomes.[8–14] The literature in older PLWH has focused mainly on drug–drug interactions (DDIs) involving ARVs, with only a few studies having focused explicitly on prescribing issues. In a retrospective study of 89 PLWH aged ≥ 60 years, mainly male Caucasians, 52% had at least one PIM based on the 2012 AGS Beers criteria.[15] In this study, the main drugs involved in PIMs were testosterone, ibuprofen, zolpidem, and lorazepam, and 17% of PLWH received anticholinergic drugs. In a prospective study involving 248 PLWH aged ≥ 50 years, two-thirds of whom were male,[16] PIMs were identified in 63% and 54% of individuals according to the 2012 AGS Beers and the STOPP/START criteria, respectively. Benzodiazepines, NSAIDs, first-generation antihistamines, tricyclic antidepressants, and nonbenzodiazepinehypnotics were the most common PIMs, according to the 2012 AGS Beers criteria.[16] In a retrospective study of the Swiss HIV Cohort, two-thirds of 111 PLWH aged ≥ 75 years, mainly male, had at least one potentially inappropriate prescribing issue according to the 2012 AGS Beers and STOPP/START criteria.[17] Potential prescribing errors in this last study included unadjusted dosage, no indication, medication omission, medication not appropriate in older individuals, deleterious DDIs, and treatment duration exceeding recommendations; of note, the proportion of patients with more than one prescribing issue was significantly higher in those with polypharmacy.

The prevalence of PIM in our study is lower than the prevalences reported in previous studies performed in elderly PLWH[15–17] or in elderly Spanish uninfected individuals,[18] a discrepancy that is probably explained by the fact that we focused exclusively on the prescription of inappropriate drugs and not on other issues such as medication omission, inappropriate dosing, or no indication. Consistent with data from studies in elderly individuals with and without HIV infection, the most frequently observed PIMs were benzodiazepines and NSAIDs.[3,15,16] Older PLWH have increased sensitivity to benzodiazepines and decreased metabolism of long-acting agents; in general, all benzodiazepines increase the risk of cognitive impairment, delirium, falls, fractures, and motor vehicle crashes in older adults. NSAIDs increase the risk of gastrointestinal bleeding or peptic ulcer disease in high-risk adults and can increase blood pressure and induce kidney injury.[4]

In our study, 15% of older PLWH received anticholinergic drugs, medications to be avoided in older people because they are associated with a wide variety of adverse effects, both peripheral (constipation, oral and ocular dryness, tachycardia and urinary retention) and central (agitation, confusion, delirium, falls, hallucinations and cognitive disorders), to which this population is particularly susceptible.[4]

Factors independently associated with increased risk of PIM in our study included polypharmacy, something frequently found in other studies, and female sex. Gender-related differences in polypharmacy could explain the increased risk of having a PIM in women. Some of these differences may be explained by the more frequent contact with the health care system among women, which may provide women with extra opportunity for detection of diseases and receipt of prescriptions, and also gender-related biological differences in the occurrence of specific comorbidities associated with a chronic need for medication.[19,20]

Our study is limited by the absence of information about comorbidities, by the lack of information about the medical management of patients, including potential dosage adjustments, and by the absence of information about clinical outcomes of patients with PIMs. Furthermore, over-the-counter drugs were not included in the analysis and therefore the use of medications like ibuprofen and related PIM might have been underestimated. The strengths of our study include its population-based design, the large sample size, and the automatic retrieval of both ARVs and co-medications from an official comprehensive prescription database.

In conclusion, we found that, in the region of Madrid, PIM was highly prevalent in older PLWH, particularly among women and individuals with polypharmacy, and involved mainly benzodiazepines and NSAIDs. Interventions to limit PIMs include education about prescribing principles in older PLWH as well as medication reconciliation, review and prioritization according to the risks/benefits for a given patient to prevent unnecessary polypharmacy and prescription of harmful medications. In this regard, a multidisciplinary team approach is advised to optimize treatment of multimorbid older PLWH. Importantly, consultation length should be adapted to allow sufficient time to review prescriptions, particularly in complex and vulnerable patients. Finally, future work should aim to develop computerized prescription systems integrating several tools to screen for DDIs and inappropriate drug use to assist clinicians efficiently with the identification and prevention of prescribing errors.[13,21]

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