Prescribing issues in elderly individuals living with HIV

ABSTRACT

Introduction: Combined antiretroviral therapy has transformed HIV infection into a chronic disease thus people living with HIV (PLWH) live longer. As a result, the management of HIV infection is becoming more challenging as elderly experience age-related comorbidities leading to complex polypharmacy and a higher risk for drug-drug or drug–disease interactions. Furthermore, age-related physiological changes affect pharmacokinetics and pharmacodynamics thereby predisposing elderly PLWH to incorrect dosing or inappropriate prescribing and consequently to adverse drug reactions and the subsequent risk of starting a prescribing cascade.

Areas covered: This review discusses the demographics of the aging HIV population, physiological changes and their impact on drug response as well as comorbidities. Particular emphasis is placed on common prescribing issues in elderly PLWH including drug–drug interactions with antiretroviral drugs. A PubMed search was used to compile relevant publications until February 2019.

Expert opinion: Prescribing issues are highly prevalent in elderly PLWH thus highlighting the need for education on geriatric prescribing principles. Adverse health outcomes potentially associated with polypharmacy and inappropriate prescribing should promote interventions to prevent harm including medication reconciliation, medication review, and medication prioritization according to the risks/benefits for a given patient. A multidisciplinary team approach is recommended for the care of elderly PLWH.

KEYWORDS:

• HIV
• elderly
• inappropriate prescribing
• antiretroviral drug
• drug-drug interactions
• polypharmacy

Article Highlights

• Effective antiretroviral therapy has transformed HIV infection into a chronic condition allowing HIV-infected individuals to live close to normal life expectancy resulting in a growing number of elderly PLWH.

• Age-related pharmacokinetic and pharmacodynamic changes and comorbidities predispose elderly PLWH to inappropriate prescribing, DDIs, drug-disease interactions, adverse drug reactions, and unnecessary polypharmacy, which may lead to adverse health outcomes.

• Strategies should be implemented to prevent prescribing errors including education on prescribing principles for the elderly and on DDIs with antiretroviral drugs; medication reconciliation and regular medication review as well as medication prioritization according to the risks/benefits for a given patient; adapted consultation times for prescribing and effective communication with the patient and between the patient’s health-care providers.

• Elderly PLWH should be included in clinical trials to improve our understanding on drug pharmacokinetics, DDIs or drug responses with aging.

• Future developments should include computerized prescription systems integrating screening tools for inappropriate drug use, drug omission, incorrect dosing and DDIs with HIV drugs and between non-HIV drugs to efficiently assist clinicians in the identification and prevention of prescribing errors.

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.

Additional information

Funding

C Marzolini has been supported by a grant of the Swiss National Foundation (Grant number 166204), the OPO Foundation, and the Isaac Dreyfus Foundation.