Polypharmacy in HIV: recent insights and future directions

Abstract

Purpose of review: Update findings regarding polypharmacy among people with HIV (PWH) and consider what research is most needed. Recent findings: Among PWH, polypharmacy is common, occurs in middle age, and is predominantly due to non-antiretroviral (ARV) medications. Many studies have demonstrated strong associations between polypharmacy and receipt of potentially inappropriate medications (PIMS), but few have considered actual adverse events. Falls, delirium, pneumonia, hospitalization, and mortality are associated with polypharmacy among PWH and risks remain after adjustment for severity of illness. Summary: Polypharmacy is a growing problem and mechanisms of injury likely include potentially inappropriate medications, total drug burden, known pairwise drug interactions, higher level drug interactions, drug-gene interactions, and drug-substance use interactions (alcohol, extra-medical prescription medication, and drug use). Before we can effectively design interventions, we need to use observational data to gain a better understanding of the modifiable mechanisms of injury. Because sicker individuals take more medications, analyses must account for severity of illness. Because self-report of substance use may be inaccurate, direct biomarkers such as phosphatidylethanol (PEth) for alcohol are needed. Large samples including electronic health records, genetics, accurate measures of substance use, and state of the art statistical and artificial intelligence techniques are needed to advance our understanding and inform clinical management of polypharmacy in PWH.

Antiretroviral Drugs for Treatment and Prevention of HIV Infection in Adults

“…Among persons with HIV, comorbid conditions appear to occur at a younger age and polypharmacy is present earlier than in people without HIV . Commonly prescribed medications in older persons with HIV include lipid-lowering agents, antihypertensive agents, antidepressants, analgesics (nonopioid and opioid), hypoglycemic agents, proton pump inhibitors, and steroid and nonsteroid inhalers …”

“…Polypharmacy may lead to an increased risk of ART nonadherence owing to pill fatigue or confusion among older individuals taking numerous medications. Close and sustained attention to polypharmacy is recommended in the management of older persons with HIV (evidence rating: AIII) …”

Long‐term success for people living with HIV: A framework to guide practice

“…Therefore, it is important to ensure that ART does not cause or exacerbate other comorbid conditions. Assessing whether other equally effective treatment options (including non‐pharmacological treatments) can be used to avoid interactions and treat symptoms is important to reduce the impact of these conditions on people living with HIV [17, 38].…”

Delirium among people aging with and without HIV: Role of alcohol and Neurocognitively active medications

“…Among PWoH, NCAMs including both anticholinergic medications, such as diphenhydramine, paroxetine, and quetiapine, and non-anticholinergic medications including opioids, sedatives, and anticonvulsants have potentially serious drug interactions contributing to delirium in addition to their independent risk for delirium, especially in the setting of polypharmacy. [13][14][15][16][17] As a result, medications, especially benzodiazepines, anticholinergics, and antipsychotics, are often considered "potentially inappropriate" especially in the context of aging. 18 Similarly, among PWoH, unhealthy alcohol use is an independent risk factor for delirium 15 and the neurocognitive effects of NCAMs are known to interact with unhealthy alcohol use.…”