Growing Older on Antiretrovirals: Polypharmacy Risk

Until recently, polypharmacy was not a tremendous concern among individuals with HIV. HIV was considered to be an infection associated with increased morbidity. However, statisticians estimate that 75% of individuals with HIV will be 50 years or older by 2030. As they age, they develop chronic conditions associated with older age. And, they take more medication.

This is the topic of a review article published in the June 2017 issue of the journal AIDS. Assembled by pharmacists who practice at Johns Hopkins University in Baltimore, Maryland, this article focuses specifically on polypharmacy challenges.

Individuals with HIV have almost double the risk of ischemic heart disease, heart failure, and myocardial infection compared to individuals who are not infected. This elevated risk is attributed to chronic inflammation and long-term adverse effects of many antivirals. In their discussion of cardiac disease, the authors give ample attention to CYP drug interactions. They also look at the full range of cardiac medications and indicate which are most appropriate to use in patients with HIV.

Coverage of statins is of great significance in individuals with HIV because they experience dyslipidemia significantly more often than others. Many of the NNRTI- and protease inhibitor-based regimens contribute to dyslipidemia.

Anticoagulation is of growing concern in this population also. The authors indicate that the newer anticoagulants may be preferred over warfarin primarily based on convenience. However, it is noted that apixaban and rivaroxaban are CYP3A4 and P-gp substrates, and dabigatron and edoxaban are P-gp substrates. This heightens the need to monitor for drug interactions.

The authors also discuss hypertension and diabetes. Individuals with HIV are at 4 times the risk of developing diabetes. Management in this population is similar to management in patients who do not have HIV negative, with metformin as the first-line therapy.

Finally, the authors discuss malignancy, which has been a problem for the HIV population since the epidemic began. Here too, drug interactions are a primary concern when patients need chemotherapy. The authors also cover common concerns such as hepatotoxicity and QT prolongation.

This is an important publication for community pharmacists who are seen growing numbers of patients with HIV aging.

Reference

Smith JM, Flexner C. The challenge of polypharmacy in an aging population and implications for future antiretroviral therapy development. AIDS. 2017 Jun 1;31 Suppl 2:S173-S184.