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Increased incidence of glaucoma medication usage in middle-aged Australian males taking antiretroviral medication - a population-based study
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Mitochondrial injury is a well-documented side effect of nucleoside reverse transcriptase inhibitors (NRTI) [36, 37], and is important in the pathogenesis of glaucoma [38]. While drug-induced mitochondrial toxicity is less pronounced in later generations of NRTIs it may still lead to an optic neuropathy and the prescription of glaucoma drops [39-41]. While plausible, the causal link between ART and glaucomatous optic neuropathy will require further investigation to elucidate.
Our study shows that young patients receiving ART have a higher incidence of use of IOP lowering drops. This is most pronounced in males aged 30 to 49. While this raises suspicion that HIV may be associated with the development of glaucoma or similar optic nerve disease, further prospective studies with a larger sample size will be required to elucidate any causation, whether it be disease-related or medication-related, or whether HIV/AIDS causes ocular diseases that can mimic glaucoma.
We identified an increased OR of up to 2.23 for Australian males aged 30-49 on HIV medication to require IOP-lowering therapy. A similar trend was seen with females in this age group (p = 0.062), although the study population was likely too small to elucidate a statistically significant effect. We have several proposed explanations for why patients on ART appear to have a higher rate of usage of IOP-lowering therapy that we explore herein.
The first theory would be the possibility that HIV/AIDS causes glaucoma. While HIV and especially AIDS is associated with optic nerve dysfunction, glaucomatous injury to the optic nerve has never been described in the literature. Rather, HIV and a low CD4 count are ostensibly associated with hypotony and thickening of the RNFL in the superior and temporal quadrants [30]
There are, however, other explanations for why this patient group may have a higher incidence of being prescribed IOP-lowering medication.
Abstract
Background
To investigate a possible association between glaucoma and the use of anti-retroviral therapy (ART) for HIV in the Australian population.
Methods
A retrospective review of Australian Pharmaceutical Benefits Scheme data was undertaken from July 2012 to December 2016, inclusive. Three patient groups were compared: those on both topical intraocular pressure (IOP) -lowering medication and ART, those on ART only, and those on IOP-lowering medication only, using the 2016 Australian resident population to estimate prevalence. Odds ratios (95% confidence intervals, [CI]) with Fishers exact test for p values were calculated stratified by age and gender.
Results
The number of prescriptions for topical glaucoma medications in the general Australian population increased progressively by age with a peak prevalence in those aged 80 years and above. Prevalence of ART was highest in males aged 40-49 and 50-59 years (0.41% [CI 0.40, 0.42] and 0.44% [CI 0.43, 0.45], respectively). Our analysis identified an increase in the prescription of IOP-lowering medication in males on ART aged 30-39 (OR 2.23 [CI 1.32, 3.75], p = 0.007) and 40-49 (OR 1.86 [CI 1.42, 2.43], p < 0.001), compared to those not on ART. There were no statistically significant increased odds for females or males aged 50 years or more.
Conclusion
Compared with the known increase in glaucoma prevalence with age in the general Australian population, a statistically significant increased prevalence in use of IOP-lowering medications was found in males on ART aged 30-49 years. The mechanism for this is yet to be determined, but possible causes include sequelae of HIV infection, a drug-induced side effect, or increased medical surveillance.
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