Relationship of Polypharmacy to HIV RNA Suppression in People Aged ≥ 50 Years Living With HIV

MM Murray; J Lin; A Buros Stein; ML Wilcox; J Cottreau; M Postelnick; FJ Palella

Disclosures

HIV Medicine. 2021;22(8):742-749. 

In This Article

Abstract and Introduction

Abstract

Objectives: People living with HIV (PLWH) aged ≥ 50 years face unique challenges regarding their medication therapies, especially antiretroviral therapy (ART). Use of ARTs, along with medications for comorbidities, may lead to adverse events, drug–drug interactions (DDIs) and poor adherence. The objective of this study was to identify the number of medications above which PLWH aged ≥ 50 years are less likely to be virally suppressed and to describe other associated patient-specific risk factors.

Methods: This was a cross-sectional study of PLWH aged ≥ 50 years, prescribed ART, and seen at least once in the Northwestern Infectious Disease Center between 1 June 2013 and 31 May 2015. Variables concerning medication use and comorbidities were collected. The primary outcome was the presence of an undetectable plasma HIV RNA level (viral load).

Results: Among the 621 included patients, there was a higher percentage taking ≤ 15 medications with an undetectable plasma HIV RNA (n = 453; 80.6%) vs. patients taking > 15 medications (n = 40; 67.8%; P = 0.03). Taking > 15 medications [odds ratio (OR) 0.49; 95% confidence interval (CI) 0.26–0.96], pulmonary disease (OR 0.54; 95% CI 0.3–0.97) and CD4 T-lymphocyte count < 200 cells/μL (OR 0.39; 95% CI 0.22–0.68) decreased the odds of having an undetectable plasma HIV RNA.

Conclusions: PLWH taking > 15 medications were less likely to have an undetectable HIV RNA. Further studies are needed to evaluate the impact of overall medication economic burden on clinical outcomes among PLWH ≥ 50 years of age.

Introduction

Antiretroviral therapy (ART) has significantly decreased morbidity and mortality in people living with HIV (PLWH).[1] With proper maintenance therapy and adherence, HIV has become a manageable chronic condition, increasing the lifespan of PLWH dramatically. With this change in prognosis, it is estimated that 73% of PLWH will be at least 50 years of age by 2030.[2] Described as "older adults," PLWH ≥ 50 years of age face unique challenges regarding their medication therapies.[3]

Modern ART regimens are well tolerated with fewer adverse events (AEs) than older regimens.[4] There are now fewer patients who switch or discontinue ART compared with a decade ago, and ART switches occur less often for reasons of virological nonsuppression.[5] Despite evidence that PLWH have become more adherent to ART, long-term toxicities of such medications are not fully understood.[4] Long-term toxicity can lead to impaired health as well as reduced quality of life. Also, ART-related AEs may contribute to the economic burden and health care resource utilization associated with HIV treatment.[4]

As PLWH age, they face many chronic comorbid illnesses such as dyslipidaemia, cognitive decline, liver disease, osteoporosis, diabetes, hypertension and cancer. PLWH ≥ 50 years of age simultaneously must undergo treatment for HIV and their comorbid illnesses, some of which may lead to cardiovascular, metabolic and renal complications.[6] Also, aging PLWH may experience slower and diminished immune restoration despite virological suppression.[7] PLWH may have weaker organ system reserve, chronic inflammation and immune dysfunction.[7,8]

Polypharmacy has been associated with increasing age and increased risk of AEs, medication errors, hospitalization, poor adherence and drug–drug interactions (DDIs).[9–11] PLWH are more likely to experience adverse polypharmacy effects as a consequence of the above-mentioned factors and a greater number of comorbidities.[7,12,13] Furthermore, aging-associated chronic comorbid illnesses often necessitate additional drug treatments;[14] these comorbid conditions become more central to overall health, morbidity experienced, and treatments received among aging PLWH.[15] As a consequence, the convergence of non-HIV-related comorbidities and their drug treatments among aging PLWH increasingly results in the presence of, and concerns related to, polypharmacy.[16] The need for a greater number of non-ART medications places PLWH ≥ 50 years old at greater risk for DDIs than younger PLWH.[16] ARTs, along with medications for comorbidities, may produce AEs, DDIs and poor adherence.[17]

The combination of long-term ART, polypharmacy, pharmacodynamic and pharmacokinetic alterations, and comorbidities in PLWH aged ≥ 50 years is a challenge for health care providers and patients. The objective of this study was to identify the number of medications above which PLWH aged ≥ 50 years are less likely to be virally suppressed and to describe other associated patient-specific risk factors.

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