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Polypharmacy in 94% of Older HIV
Group, Inappropriate Meds Frequent
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11th International Workshop on HIV & Aging Virtual Meeting, September 30 to October 2, 2020
By Mark Mascolini for NATAP and Virology Education
Almost everyone in a 50 or older HIV group at a San Francisco public hospital took 5 or more non-HIV drugs (defined here as polypharmacy) [1]. A pharmacist review showed that almost two thirds of the group took a potentially inappropriate medication (PIM), a problem that decreased significantly after the pharmacist intervention.
Polypharmacy remains a growing concern as people with HIV live to older ages with their infection and accumulating comorbidities. University of California, San Francisco (UCSF) researchers who conducted this study noted that polypharmacy inflates the risk of drug-drug interactions (DDIs), adverse effects, and drug toxicity. As the number of drugs prescribed for any individual climbs, so does the possibility of PIMs.
The UCSF team conducted this study in HIV ward patients at San Francisco General Hospital, a public hospital that cares for many people with limited or no insurance. The researchers aimed to identify prescribing problems in HIV patients 50 or older at a geriatric consultation with a clinical pharmacist and geriatrician between July 2016 and the end of 2018. Six months after that initial visit, a primary care physician rechecked each person’s total pill count, DDIs, and PIMs (using BEERS, STOPP, and START criteria).*
The researchers emphasized the crucial role of a clinical pharmacist in this process (1) to recognize and resolve PIMs, DDIs, and adverse effects, (2) to conduct a medication reconciliation, and (3) to start patient education and recommend medication adherence strategies.
The study involved 123 HIV-positive adults averaging 64 years in age (range 50 to 81). Most of the group members, 93%, were men, 98% took antiretrovirals (78% of them an integrase inhibitor), 92% had an undetectable viral load, and CD4 count averaged 515 (range 365 to 686). Half of the group had depression, hypertension, and/or hyperlipidemia, and one third reported falls.
All but 7 people in this group, 94%, met polypharmacy criteria, 81% had 1 or more DDI, and 62% had 1 or more PIMs. Total daily pill count averaged 16.4, while DDIs averaged 3.6. The most frequent non-HIV drugs were atorvastatin (6%), aspirin (5%), benazepril (3%), and gabapentin (3%). The most frequent prescribing problems involved nonsteroidal antiinflammatories (NSAIDs) and proton pump inhibitors (PPIs) by BEERS criteria, duplicate drug class prescription and regular opioids without a concomitant laxative by STOPP criteria, and the opioid-laxative problem and a 5-alpha reductase inhibitor with symptomatic prostatism by START criteria.
Six months after the initial pharmacist/geriatrician visit, total daily pill count inched up from an average 16.4 to 16.8, while total daily antiretroviral pills slipped from 2.5 to 2.4 (P = 0.06). Combined total medications rose from 13.4 at the initial visit to 13.9 at the 6-month follow-up, a nearly significant jump (P = 0.08).
From the initial visit to the 6-month visit, average DDIs per person dwindled nonsignificantly from 3.6 to 3.2 (P = 0.36). Total PIMs per person fell significantly from 1.6 to 1.4 (P = 0.002). Average PIM decline proved significant when measured by BEERS criteria (1.2 to 1.1, P = 0.03) or STOPP criteria (0.2 to 0.1, P = 0.02) but not by START criteria (0.2 to 0.2).
The researchers concluded that the pharmacist/geriatrician intervention significantly cut the number of PIMs in this older HIV population. They suggested that failure to reduce DDIs or pill burden in this analysis could reflect incomplete documentation in electronic medical records or comorbidity progression.
*BEERS criteria come from the American Geriatric Society, START is the Screening Tool to Alert to Right Treatment, and STOPP is the Screening Tool of Older Persons’ Prescriptions.
Reference
1. Chen V, Grochowski J, Tang E, Li J, Zhao M, Greene M. Evaluation of prescribing issues in older adults living with HIV. 11th International Workshop on HIV & Aging Virtual Meeting, September 30 to October 2, 2020. Abstract 4.
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