Polypharmacy and risk of falls and fractures for patients with HIV infection and substance dependence

Abstract

Although people with HIV infection (PLWH) are at higher risk of polypharmacy and substance use, there is limited knowledge about potential harms associated with polypharmacy such as falls and fractures in this population. The study objective was to determine whether polypharmacy, as measured by the number and type of medication, is associated with falls and fractures among PLWH and DSM-IV substance dependence in the past year or ever injection drug use (IDU). We identified the number of medications by electronic medical record review in the following categories: (i) systemically active, (ii) non-antiretroviral (non-ARV), (iii) sedating, (iv) non-sedating as well as any opioid medication and any non-opioid sedating medication. Outcomes were self-reported (1) fall/accident requiring medical attention and (2) fracture in the previous year. Separate logistic regression models were fitted for medications in each category and each outcome. Among 250 participants, the odds of a fall requiring medical attention were higher with each additional medication overall (odds ratio [OR] 1.12, 95% Confidence Interval [CI] = 1.05, 1.18), each additional non-ARV medication (OR 1.13, 95%CI = 1.06, 1.20), each additional sedating medication (OR 1.36, 95%CI = 1.14, 1.62), and a non-opioid sedating medication (OR 2.89, 95%CI = 1.06, 7.85) but not with an additional non-sedating medication or opioid medication. In receiver operating characteristic (ROC) curve analyses, optimal cutoffs for predicting falls were: ≥8 overall and ≥2 sedating medications. Odds ratios for fracture in the previous year were OR 1.05, 95%CI = 0.97, 1.13 for each additional medication overall and OR 1.11, 95%CI = 0.89, 1.38 for each additional sedating medication. In PLWH and substance dependence or ever IDU, a higher number of medications was associated with greater odds of having a fall requiring medical attention. The association appeared to be driven largely by sedating medications. Future studies should determine if reducing such polypharmacy, particularly sedating medications, lowers the risk of falls.

Polypharmacy, Hazardous Alcohol and Illicit Substance Use, and Serious Falls Among PLWH and Uninfected Comparators

“…This association is established among older adults 26,27 and has been suggested by other investigators among PLWH. 4,12 The stronger association between benzodiazepines, muscle relaxants and serious falls among PLWH relative to uninfected comparators is particularly striking. These medications may interact with ART or direct effects of the virus may increase their impact.…”

“…4 Another study that included uninfected individuals found that hepatitis C virus infection (HCV), female sex, obesity, smoking and clinical imbalance symptoms were associated with falls, but that age, HIV serostatus, and other comorbidities were not. 5 Others suggest that comorbidity count 7 and the number of medications prescribed 11,12 are associated with fall risk among PLWH, but neither of these studies provided comparisons with uninfected individuals.…”

The beginning of the end: A qualitative study of falls among HIV+ individuals

“…Fall research in the HIV+ population identified multimorbidity, polypharmacy, and functional impairment as important fall risk factors [ 1 ]. In addition to the total number of medications prescribed (polypharmacy), specific medications were associated with falls, particularly those that were active in the central nervous system (CNS) such as opioids, muscle relaxants, and benzodiazepines [ 7 , 8 ]. Frailty and peripheral neuropathy have also been associated with falls in this population as have symptoms of dizziness or imbalance [ 9 – 11 ].…”

Fall History and Associated Factors Among Adults Living With HIV-1 in the Cape Winelands, South Africa: An Exploratory Investigation

“…The high rate noted in our young cohort may be explained by a different HIV profile to that of PWH in HIC studies. Although most HIC studies found no association between falls and viral load, these studies included cohorts with mostly undetectable viral loads [1, 5, 8, 12, 30]. The discordance noted between ART use and virologic suppression in our sample may be reflective of South African PWH [37], where poor ART adherence or virological failure may be common [16].…”