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One Quarter of 65+ Group With HIV and Polypharmacy Fall, 10% Seek Emergency Care
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IDWeek 2020, October 22-25, 2020
Mark Mascolini
Analysis of 104 HIV-positive people 65 or older documented polypharmacy in all of them and found that more than one quarter fell in 3.5 years [1]. More than 1 in 10 of these older people had to seek emergency care during the study period.
Morbidities and physiologic changes that arise with aging lead to higher rates of polypharmacy, defined in this University of New Mexico study as 5 or more non-HIV medications. Greater drug use drives a higher risk of inappropriate prescribing, drug-drug interactions, and consequent adverse events.
Researchers at the University of New Mexico and the University Hospital Basel collaborated to assess the rate and impact of polypharmacy in HIV-positive people at least 65 years old who received at least 1 potentially inappropriate prescription (PIP). This retrospective analysis ran from January 1, 2015 to August 21, 2018. The researchers cataloged adverse events related to PIPs, severity of adverse events (according to the WHO scale for adverse event grade), and hospital admissions. The investigators used 5 well-known measures of inappropriate prescribing: Beers criteria, the STOPP and START screening tools, and the online Lexicomp and University of Liverpool drug-interaction databases.
Among the 104 participants, 51 (49%) crossed the 1-or-more-PIP threshold by Beers criteria and 60 (58%) by STOPP criteria. Nonsteroidal antiinflammatories (NSAIDS) proved the most frequently inappropriately prescribed drugs, followed by benzodiazepines and first-generation antihistamines. The group had a median age of 68 (interquartile range [IQR] 66 to 70), and 92 study participants (88.5%) were men. Ninety participants (86.5%) were white, 29 (28%) Hispanic, and 5 (5%) black.
The group had been diagnosed with HIV infection for a median of 22 years (IQR 14 to 28), and 92 (88.5%) had an undetectable viral load. Median CD4 count stood at 589 (IQR 431 to 819). All 104 participants met the polypharmacy definition, taking a median of 8 non-HIV drugs (IQR 6 to 12). Two thirds of the group took a integrase inhibitor-based antiretroviral regimen.
Thirty of 104 people (29%) had at least 1 adverse event related to a PIP, with 53 PIP-related adverse events in all. Twenty-eight of 104 people (27%) fell, 20 (19%) had 1 or more severe adverse events, 14 (13.5%) went to the emergency room 1 or more times, and 2 (2%) got admitted to the hospital. Almost half of study participants with an adverse PIP-related event (14 of 30, 47%) went to the emergency room. Of the 53 adverse events, falls were by far the most frequent, accounting for 28 events (53%), followed by bleeds (7, 13%) and fractures (5, 9%).
Multivariate analysis determined that each additional non-HIV medication raised odds of an adverse event 20% (adjusted odds ratio [aOR] 1.2, 95% confidence interval [CI] 1.1 to 1.3). Meeting Beers criteria for inappropriate prescribing tripled the odds of an adverse event (aOR 2.9, 95% CI 1.1 to 8.2), as did meeting STOPP criteria (aOR 3.0, not significant at 95% CI of 0.9 to 9.2). Logistic regression adjusted for age, gender, race, and CD4 count determined that taking 7 or more non-HIV medication (vs fewer than 7) ballooned odds of an adverse event more than 5-fold (aOR 5.4, 95% CI 1.8 to 16.2).
The University of New Mexico researchers cautioned that they may have underestimated the number of adverse events due to PIP because (1) they collected only the most concerning adverse events and (2) electronic medical records do not capture all adverse events. They suggested three strategies to prevent harm from inappropriate prescribing: (1) medication review, (2) medication reconciliation, and (3) medication prioritization according to each individual's risks and benefits.
Reference
1. Cinquegrani M, Cabanilla MG, Ryan KL, Marzolini C, Jakeman B. Adverse events due to inappropriate prescribing in older adults living with HIV. IDWeek 2020, October 22-25, 2020. Abstract 925.
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