Vol 2 No 3 (2019): International Journal of Aging Research
Research Articles

Prevalence of Polypharmacy and Association to Pharmacotherapy Complexity in Older HIV-Positive Patients. The Sevihlla Study

1Ramón Morillo-Verdugo. PharmD, 1Mª de las Aguas Robustillo-Cortés*. PharmD., 2Laila Abdel-Kader Martín. PharmD., 3María Álvarez de Sotomayor Paz. PhD., 4Fernando Lozano de León Naranjo. MD, 5Carmen Victoria Almeida-González. MS
1Valme Hospital (Pharmacy Department). Seville, 41014, Spain. 2Virgen del Rocío Hospital (Pharmacy Department), Seville, 41013, Spain. 3School of Pharmacy. University of Seville. 4Unit of Infectious Diseases and Microbiology, Valme Hospital, Seville, 41014, Spain. 5University of Seville.
Keywords
  • HIV, Polypharmacy, Pharmacotherapy Complexity, Aging
How to Cite
1Ramón Morillo-Verdugo. PharmD, 1Mª de las Aguas Robustillo-Cortés*. PharmD., 2Laila Abdel-Kader Martín. PharmD., 3María Álvarez de Sotomayor Paz. PhD., 4Fernando Lozano de León Naranjo. MD, 5Carmen Victoria Almeida-González. MS. (2019). Prevalence of Polypharmacy and Association to Pharmacotherapy Complexity in Older HIV-Positive Patients. The Sevihlla Study. International Journal of Aging Research, 2(3), 35. https://doi.org/10.28933/ijoar-2019-2606

Abstract

Background: Increased life expectancy of older HIV-positive patients has been associated to a parallel increase in age-related comorbidities.
Objectives: To ascertain the prevalence of polypharmacy and its association to pharmacotherapy complexity, as measured by the Medication Regimen Complexity Index, in older HIV-positive patients; to calculate the median value of pharmacotherapy complexity; to identify polypharmacy and multimorbidity patterns; and to address adherence to antiretroviral and concomitant drugs.
Methods: A cross-sectional, observational study was conducted in patients over 50 years of age receiving active antiretroviral drugs during 2014 at outpatient pharmacy services of a tertiary hospital in Spain. Data collected from the electronic medical record included demographic, clinical and comorbidity related endpoints.
The primary endpoint was the proportion of patients with polypharmacy and major polypharmacy. Polypharmacy was defined as treatment with six or more drugs (including antiretroviral). Major polypharmacy (more than 11 drugs) was also considered.
Patients was categorized according to their polypharmacy pattern. Three patterns were applied based on age of participants: cardiovascular, depression-anxiety, and chronic obstructive pulmonary (COPD) disease patterns. A patient was classified into a pattern when at least three drugs of the treatment were in the same pattern.
Antiretroviral treatment adherence was measured using the SMAQ questionnaire and hospital dispensing records. Adherence to concomitant medication was measured using the Morisky-Green questionnaire and electronic pharmacy dispensing records.
Pharmacotherapy complexity index, as assessed by MRCI, was also considered. Patients were classified as low MRCI (less than 14 points) or high MRCI (more than 14 points).
Results: The study sample consisted of 223 patients (86.5% men), with a median age of 53.0 years. More than 80.0% of the patients were viro-inmunological controlled. Prevalence of polypharmacy was 56.1%. The median value of pharmacotherapy complexity was 11.0. The main contribution to this value was from the concomitant medication.
The polypharmacy pattern mainly calculated was cardiovascular (60.0%) and the multimorbidity pattern was cardiometabolic (73.8%).
Presence of polypharmacy was associated to greater pharmacotherapy complexity (p<0,001). Adequate adherence to the antiretroviral and to concomitant medication was found in 83.6% and 37.9% of patients respectively.
Conclusions: More than a half of the older HIV-positive patients received six or more different drugs with a significant pharmacotherapy complexity showing adequate adherence to antiretroviral but not to concomitant drugs. Cardiovascular conditions were most common in terms of prescriptions and comorbidities.

References

1. Tseng A, Szadkowski L, Walmsley S, Salit I, Raboud J. Association of Age With Polypharmacy and Risk of Drug Interactions With Antiretroviral Medications in HIV-Positive Patients. Ann Pharmacother. 2013;47(11):1429-1439. doi:10.1177/1060028013504075.
2. High KP, Brennan-Ing M, Clifford DB, et al. HIV and aging: state of knowledge and areas of critical need for research. A report to the NIH Office of AIDS Research by the HIV and Aging Working Group. J Acquir Immune Defic Syndr. 2012;60 Suppl 1:S1-18. doi:10.1097/QAI.0b013e31825a3668.
3. Gleason LJ, Luque AE, Shah K. Polypharmacy in the HIV-infected older adult population. Clin Interv Aging. 2013;8:749-763. doi:10.2147/CIA.S37738.
4. Gnjidic D, Hilmer SN, Blyth FM, et al. Polypharmacy cutoff and outcomes: five or more medicines were used to identify community-dwelling older men at risk of different adverse outcomes. J Clin Epidemiol. 2012;65(9):989-995. doi:10.1016/j.jclinepi.2012.02.018.
5. Gimeno-Gracia M, Crusells-Canales MJ, Rabanaque-Hernández MJ. Clinical characteristics and antiretroviral treatment of older HIV-infected patients. Int J Clin Pharm. 2014;36(6):1190-1195. doi:10.1007/s11096-014-0015-x.
6. Grupo de expertos de la Secretaría del Plan Nacional sobre el SIDA (SPNS), Sociedad Española de Geriatría y Gerontología (SEGG). Documento de consenso sobre edad avanzada e infección por el virus de la inmunodeficiencia humana. 2015;(Noviembre).
7. Smith JM, Flexner C. The challenge of polypharmacy in an aging population and implications for future antiretroviral therapy development. AIDS. 2017;31 Suppl 2:S173-S184. doi:10.1097/QAD.0000000000001401.
8. Gimeno-Gracia M, Crusells-Canales MJ, Javier Armesto-Gómez F, Rabanaque-Hernández MJ. Prevalence of concomitant medications in older HIV+ patients and comparison with general population. HIV Clin Trials. 2015;16(3):117-124. doi:10.1179/1528433614Z.0000000012.
9. Cantudo-Cuenca MR, Jiménez-Galán R, Almeida-González C V., Morillo-Verdugo R. Concurrent Use of Comedications Reduces Adherence to Antiretroviral Therapy Among HIV-Infected Patients. J Manag Care Pharm. 2014;20(8):844-850. doi:10.18553/jmcp.2014.20.8.844.
10. Smit M, Brinkman K, Geerlings S, et al. Future challenges for clinical care of an ageing population infected with HIV: a modelling study. Lancet Infect Dis. 2015;15(7):810-818. doi:10.1016/S1473-3099(15)00056-0.
11. Marzolini C, Elzi L, Gibbons S, et al. Prevalence of comedications and effect of potential drug-drug interactions in the Swiss HIV Cohort Study. Antivir Ther. 2010;15(3):413-423. doi:10.3851/IMP1540.
12. Izquierdo YB, Agudo PM, Ramírez ÁA, Labriola CI, González CA, Verdugo RM. Influence of co-medication on the risk of clinically relevant drug interactions in patients with HIV. Eur J Hosp Pharm. 2013;20(2):88-92. doi:10.1136/ejhpharm-2012-000249.
13. Holtzman C, Armon C, Tedaldi E, et al. Polypharmacy and Risk of Antiretroviral Drug Interactions Among the Aging HIV-Infected Population. J Gen Intern Med. 2013;28(10):1302-1310. doi:10.1007/s11606-013-2449-6.
14. Martin S, Wolters PL, Calabrese SK, et al. The Antiretroviral Regimen Complexity Index. A novel method of quantifying regimen complexity. J Acquir Immune Defic Syndr. 2007;45(5):535-544. doi:10.1097/QAI.0b013e31811ed1f1.
15. Libby AM, Fish DN, Hosokawa PW, et al. Patient-level medication regimen complexity across populations with chronic disease. Clin Ther. 2013;35(4):385-398.e1. doi:10.1016/j.clinthera.2013.02.019.
16. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40(5):373-383. http://www.ncbi.nlm.nih.gov/pubmed/3558716. Accessed January 24, 2018.
17. Universidad de Colorado. Patient-level Medication Regimen Complexity in Defined Clinical Populations. http://www.ucdenver.edu/academics/colleges/pharmacy/Research/researchareas/Pages/MRCTool.aspx. Accessed September 19, 2017.
18. Calderón-Larrañaga A, Gimeno-Feliu LA, González-Rubio F, et al. Polypharmacy patterns: unravelling systematic associations between prescribed medications. Carvajal A, ed. PLoS One. 2013;8(12):e84967. doi:10.1371/journal.pone.0084967.
19. Prados-Torres A, Poblador-Plou B, Calderón-Larrañaga A, et al. Multimorbidity Patterns in Primary Care: Interactions among Chronic Diseases Using Factor Analysis. Gagnier JJ, ed. PLoS One. 2012;7(2):e32190. doi:10.1371/journal.pone.0032190.
20. Edelman EJ, Gordon KS, Glover J, McNicholl IR, Fiellin DA, Justice AC. The next therapeutic challenge in HIV: polypharmacy. Drugs Aging. 2013;30(8):613-628. doi:10.1007/s40266-013-0093-9.
21. Shah BM, Hajjar ER. Polypharmacy, Adverse Drug Reactions, and Geriatric Syndromes. Clin Geriatr Med. 2012;28(2):173-186. doi:10.1016/j.cger.2012.01.002.
22. Salazar JA, Poon I, Nair M. Clinical consequences of polypharmacy in elderly: expect the unexpected, think the unthinkable. Expert Opin Drug Saf. 2007;6(6):695-704. doi:10.1517/14740338.6.6.695.
23. Colley CA, Lucas LM. Polypharmacy: the cure becomes the disease. J Gen Intern Med. 1993;8(5):278-283. http://www.ncbi.nlm.nih.gov/pubmed/8505690. Accessed January 24, 2018.
24. Jyrkkä J, Enlund H, Lavikainen P, Sulkava R, Hartikainen S. Association of polypharmacy with nutritional status, functional ability and cognitive capacity over a three-year period in an elderly population. Pharmacoepidemiol Drug Saf. 2011;20(5):514-522. doi:10.1002/pds.2116.
25. Gandhi TK, Weingart SN, Borus J, et al. Adverse Drug Events in Ambulatory Care. N Engl J Med. 2003;348(16):1556-1564. doi:10.1056/NEJMsa020703.
26. Jyrkkä J, Enlund H, Korhonen MJ, Sulkava R, Hartikainen S. Polypharmacy status as an indicator of mortality in an elderly population. Drugs Aging. 2009;26(12):1039-1048. doi:10.2165/11319530-000000000-00000.
27. Scott Sutton S, Magagnoli J, Hardin JW. Impact of Pill Burden on Adherence, Risk of Hospitalization, and Viral Suppression in Patients with HIV Infection and AIDS Receiving Antiretroviral Therapy. Pharmacotherapy. 2016;36(4):385-401. doi:10.1002/phar.1728.
28. Guaraldi G, Menozzi M, Zona S, et al. Impact of polypharmacy on antiretroviral prescription in people living with HIV. J Antimicrob Chemother. 2017;72(2):511-514. doi:10.1093/jac/dkw437.
29. Zhou S, Martin K, Corbett A, et al. Total daily pill burden in HIV-infected patients in the southern United States. AIDS Patient Care STDS. 2014;28(6):311-317. doi:10.1089/apc.2014.0010.
30. Choudhry NK, Fischer MA, Avorn J, et al. The implications of therapeutic complexity on adherence to cardiovascular medications. Arch Intern Med. 2011;171(9):814-822. http://www.ncbi.nlm.nih.gov/pubmed/21555659. Accessed January 24, 2018.
31. Saini SD, Schoenfeld P, Kaulback K, Dubinsky MC. Effect of medication dosing frequency on adherence in chronic diseases. Am J Manag Care. 2009;15(6):e22-33. http://www.ncbi.nlm.nih.gov/pubmed/19514806. Accessed January 24, 2018.
32. Marcum ZA, Gellad WF. Medication Adherence to Multidrug Regimens. Clin Geriatr Med. 2012;28(2):287-300. doi:10.1016/j.cger.2012.01.008.
33. Pantuzza LL, Ceccato M das GB, Silveira MR, Junqueira LMR, Reis AMM. Association between medication regimen complexity and pharmacotherapy adherence: a systematic review. Eur J Clin Pharmacol. 2017;73(11):1475-1489. doi:10.1007/s00228-017-2315-2.
34. Haro Márquez C, Cantudo Cuenca MR, Almeida González CV, Morillo Verdugo R. [Patients’adherence-related beliefs about medicines prescribed for long-term conditions in HIV patients]. Farm Hosp. 2015;39(1):23-28. doi:10.7399/fh.2015.39.1.8127.
35. Borrego Y, Gómez-Fernández E, Jiménez R, Cantudo R, Almeida-González C V, Morillo R. Predictors of primary non-adherence to concomitant chronic treatment in HIV-infected patients with antiretroviral therapy. Eur J Hosp Pharm. February 2017:ejhpharm-2016-001000. doi:10.1136/ejhpharm-2016-001000.
36. Metz KR, Fish DN, Hosokawa PW, Hirsch JD, Libby AM. Patient-Level Medication Regimen Complexity in Patients With HIV. Ann Pharmacother. 2014;48(9):1129-1137. doi:10.1177/1060028014539642.
37. Hirsch JD, Metz KR, Hosokawa PW, Libby AM. Validation of a patient-level medication regimen complexity index as a possible tool to identify patients for medication therapy management intervention. Pharmacotherapy. 2014;34(8):826-835. doi:10.1002/phar.1452.
38. Wimmer BC, Cross AJ, Jokanovic N, et al. Clinical Outcomes Associated with Medication Regimen Complexity in Older People: A Systematic Review. J Am Geriatr Soc. 2017;65(4):747-753. doi:10.1111/jgs.14682.
39. Clegg A, Young J, Iliffe S, Rikkert MO, Rockwood K. Frailty in elderly people. Lancet. 2013;381(9868):752-762. doi:10.1016/S0140-6736(12)62167-9.
40. Guaraldi G, Brothers TD, Zona S, et al. A frailty index predicts survival and incident multimorbidity independent of markers of HIV disease severity. AIDS. 2015;29(13):1633-1641. doi:10.1097/QAD.0000000000000753.