An update on drug-drug interactions in older adults living with human immunodeficiency virus (HIV)

ABSTRACT

Introduction

People with HIV are living longer due to advances in antiretroviral therapy. With improved life expectancy comes an increased lifetime risk of comorbid conditions – such as cardiovascular disease and cancer – and polypharmacy. Older adults, particularly those living with HIV, are more vulnerable to drug interactions and adverse effects, resulting in negative health outcomes.

Area covered

Antiretrovirals are involved in many potential drug interactions with medications used to treat common comorbidities and geriatric conditions in an aging population of people with HIV. We review the mechanisms and management of significant drug-drug interactions involving antiretroviral medications and non-antiretroviral medications commonly used among older people living with HIV. The management of these interactions may require dose adjustments, medication switches to alternatives, enhanced monitoring, and considerations of patient- and disease-specific factors.

Expert opinion

Clinicians managing comorbid conditions among older people with HIV must be particularly vigilant to side effect profiles, drug-drug interactions, pill burden, and cost when optimizing treatment. To support healthier aging among people living with HIV, there is a growing need for antiretroviral stewardship, multidisciplinary care models, and advances that promote insight into the correlations between an individual, their conditions, and their medications.

KEYWORDS:

• HIV
• Drug interactions
• Aging
• Anti-retroviral agents
• Polypharmacy
• Pharmacology

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Article highlights

• Due to advances in highly-effective antiretroviral medications and improved HIV screening, life expectancy for people with HIV (PWH) on treatment has been increasing and now approaches that of the HIV-negative general population.

• With greater life expectancy comes an increasingly older HIV-positive population, with evolving challenges and healthcare needs; the proportion of people with HIV in older age ranges is expected to continue to rise globally over coming decades.

• Older PWH have a higher prevalence and risk of non-HIV-related comorbidities than their age-matched peers, which may include age-related or ‘geriatric’ syndromes and conditions associated with traditional risk factors, such as cardiovascular disease, diabetes mellitus, end-stage renal disease, malignancy, chronic and liver disease, certain sexually transmitted infections, and substance use disorders.

• Healthcare practitioners and their patients must be prepared to face the increasing role that comorbid conditions, including multiple concurrent comorbidities called “multimorbidity,” will play in the practical management of HIV, particular among older PWH.

• Polypharmacy is highly prevalent among older PWH, often related to long-term management of HIV and concurrent comorbid conditions, and contributes to morbidity and mortality in older persons due to drug-drug interactions, potentially inappropriate medications or dosages, and other unintended side effects.

• This review highlights many drug-drug interactions in older PWH that clinicians should be aware of when caring for this vulnerable patient demographic, with reference to additional resources that can be used at the point of care.

Common acronyms and initialisms used

Table

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

CYP (in bold lettering): major substrate or strong inhibitor/inducer

^a Antiretrovirals not shown due to uncommon use in current clinical practice: didanosine, stavudine, zidovudine; delavirdine, nevirapine; fosamprenavir, indinavir, lopinavir/ritonavir, nelfinavir, saquinavir, tipranavir

^b Cobicistat does not have HIV-1 antiretroviral activity; it is used to pharmacokinetically enhance, or “boost,” other antiretroviral drug levels

Additional information

Funding

RY Linfield is funded by National Institutes of Health (NIH) Institutional National Research Service Award T32 AI007502.