Prevalence of medication overload among older people with HIV: a MedSafer study

Abstract

Background: Older people with HIV (PWH) are at risk of polypharmacy (taking multiple medications). Most medications may be necessary and indicated to manage HIV (e.g., antiretroviral therapy [ART]) and HIV-associated comorbidities. However, some are potentially inappropriate medications (PIMs), defined as causing greater harm than benefit, which leads to medication overload. The objective of this study was to characterize polypharmacy (taking multiple medications) and medication overload (prescription of ≥ 1 PIMs) among older PWH.

Methods: This retrospective study included older PWH (aged ≥ 50 years old) attending the tertiary care HIV clinic at the McGill University Health Centre (Montreal, Canada), from June 2022-June 2023. Patient characteristics, medications, and select laboratory values (e.g., CD4 count, hemoglobin A1C) were entered into the MedSafer software identifying PIMs and classifying them according to risk of adverse drug event. We measured the prevalence of polypharmacy (≥ 5 medications prescribed, both including and excluding ART) and medication overload (≥ 1 PIMs). Multivariable logistic regression identified factors associated with medication overload.

Results: The study included 100 patients, with a median age of 59 years (IQR = 54-63; range 50-82); 42% female. Polypharmacy affected 89% of patients when including antiretroviral therapy (ART) and 60% when excluding ART. Medication overload was present in 58% of patients, and 37.4% of identified PIMs were classified as high-risk. Polypharmacy was the sole predictor of medication overload.

Conclusion: Older PWH are at significant risk of medication overload and receiving higher risk PIMs. Deprescribing PIMs in this population could improve medication appropriateness while reducing the risk of ADEs.

Keywords: Deprescribing; HIV; Older adults; Polypharmacy; Potentially inappropriate medications.

Fig. 1

Top 10 Classes of PIMs Identified by MedSafer and Within Class Count of PIMs by Risk Category. 1. ANTIDIABETICS: Flagged if a patient had an A1C lower than 7.5% and was at risk of hypoglycemia, or if medication increases hypoglycemic risk. 2. CALCIUM: Flagged if the patient is taking multiple daily doses of calcium, and because of the lack of demonstrated efficacy of calcium to prevent fractures. 3. SLEEPING PILLS: Benzodiazepines, Z-drugs, trazodone (<100 mg) and quetiapine (<100 mg) in the absence of a documented psychiatric condition. 4. PROTON-PUMP INHIBITORS: Flagged in the absence of dual anticoagulation, severe esophagitis, or prior upper gastrointestinal bleed. 5. OPIOIDS: Flagged due to serious adverse effects and limited effectiveness in relieving chronic non-cancer pain. 6. ANTIPSYCHOTICS: Quetiapine (>100mg), risperidone, paliperidone, prochlorperazine, etc. flagged if there was an absence of indication for prescription of this medication (e.g., antipsychotic monotherapy for depression, off-label use). 7. GABAPENTINOIDS: Flagged in patients without a known history of epilepsy for risk of CNS depression, cognitive impairment, peripheral edema, etc. 8. DOCUSATE: Flagged due to nonsuperiority to placebo. 9. EZETIMIBE: Limited evidence for the use of non-statin lipid-lowering drugs in preventing patient relevant cardiovascular outcomes, and potential for non CYP-mediated drug-drug interactions. 10. CLOPIDOGREL: Flagged in combination with aspirin or another anticoagulant in the absence of a recent cardiac stent or recent cardiovascular or cerebrovascular event. Abbreviations: PIM= Potentially Inappropriate Medications