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10/07/2013

Polypharmacy and Comorbidities in HIV: Associations with Mortality Discussed at ID Week 2013


A major focus of antiretroviral research has been simplification of antiretroviral (ARV) therapy. Many low-pill burden, once daily regimens are now available, improving adherence and making treatment-success achievable for many more patients. However, as HIV patients live-longer, they may develop chronic diseases of aging, many of which occur with increased frequency compared to the general population. Treatment of these illnesses complicates care by increasing pill burden, creating drug-drug interactions and may jeopardizes the gains achieved by ARV therapy simplification. Two abstracts presented at ID Week 2013 compared polypharmacy, defined as prescription of >5 non-ARV meds, in HIV-infected patients and matched HIV-negative controls. Using data from a large private health claims database, Koram et al. found more comorbid diagnoses and greater use of each of 8 classes of commonly prescribed medications over a one year observation period in both younger (age 18-49) and older (age ≥50) HIV-infected patients. More than 5 non-ARV medications were prescribed for 54% and 34% of older HIV-infected and uninfected patients, respectively, while corresponding numbers for the younger group were 35% and 19%. Edelman et al quantified medication use over a one year period in the large Veterans Aging Cohort Study database. They found high rates of comorbidities and medication use in both HIV-infected patients and matched HIV-negative controls, but reported slightly higher rates among the HIV-negative veterans. An analysis of subsequent mortality adjusted for gender, race/ethnicity and VACS index score showed an increasing hazard of death in those prescribed 3 or more medications, reaching about 2-fold for HIV-infected patients prescribed 5 or more medications and uninfected patients prescribed 8 or more medications.

Both studies show there is a large amount of polypharmacy in HIV-infected patients. The contrasting findings for the matched controls probably can be explained by higher rates of comorbid illness in the general VA care population relative to HIV-uninfected individuals with private health insurance. The association of polypharmacy with increased mortality is concerning but generates additional questions. Most likely, greater mortality is simply due to more severe underlying comorbid illnesses. However, it is possible that patients receiving polypharmacy have more toxicity and/or lower treatment efficacy resulting from drug-drug interactions or reduced adherence. Further studies of polypharmacy and mortality may provide better understanding of the relationship.

References:
1. Edelman JE, Gordon K, Akgun K et al. HIV+ Individuals on ART Are At Risk of Polypharmacy: More Medication Increases Mortality. ID Week 2013, San Francisco, CA, October 2-6, 2013, abstract 76.

2. Koram N, Vannappargari V, Sampson T, Panozzo C.  Comorbidity Prevalence and its Influence on Non-ARV Comedication Burden among HIV positive Patients. ID Week 2013, San Francisco, CA, October 2-6, 2013, abstract 323.


Source: Reporting from San Francisco for PRN News: David H Shepp, MD