A person living with HIV is already on multiple drugs, putting them at risk for polypharmacy, or medication overload. The prevalence of polypharmacy in the HIV community is not exactly known, but we do know that it is prevalent in the general public and that it could have adverse consequences both for the patient and the American health care system. Polypharmacy in people living with HIV was the subject of a talk from Jennifer Cocohoba,Pharm.D., M.A.S., AAHIVP, a pharmacist and professor at the University of California, San Francisco School of Pharmacy, at the Association of Nurses in AIDS Care conference in Portland, Oregon.
According to a study from the Lown Institute, 40% of U.S. adults take more than five medications a day, which is more than triple the percentage from two decades ago. Additionally, the more medications a person takes, the greater risk they face of serious adverse consequences, especially if patients are older. The Lown Institute posited that, if current trends continue, polypharmacy will cause 4.6 million hospitalizations between 2020 and 2030, will cost taxpayers an estimated $62 billion, and may cause early death among 150,000 older Americans.
A patient is considered to be on medication overload when they are taking five or more medications. A single pill like Truvada, which consists of tenofovir and emtricitabine, would be considered two medications, not one, which means most people living with HIV are already more than halfway toward being considered on a high number of medications.
There are several reasons behind the U.S. polypharmacy rates, including the prescribing cascade, in which a prescription for one drug often leads to a prescription to another drug to mitigate side effects, and so on. Also, patients often take over-the-counter medications not prescribed by their doctor to supplement their care.
The rates of polypharmacy in people with HIV are not exactly known, though some studies have tried to pinpoint the number. One 2018 study found that 24.4% of HIV-positive participants were taking more than five medications, not including their antiretrovirals (ARVs), compared to 11.6% of HIV-negative participants. Among people living with HIV over 50, that number rose to 46.8% by the end of the 12-year study, compared to 46% of HIV-negative patients. Another 2018 study published in AIDS found that polypharmacy was common in general, with 34% of people with HIV taking five or more non-ARV medications and 39% of HIV-negative people taking more than five medications. For both groups of people, more medications did correlate with an increase in hospitalizations.
According to Cocohoba, trying to lower the number of medications a patient takes is a decision that is ultimately up to the patient, but it is a conversation that prescribers should feel comfortable raising. Cocohoba also included tools and criteria that prescribers should utilize to determine whether patients are taking the right number of medications, including the Screening Tool to Alert Doctors to Right Treatments (START), the Screening Tool of Older People's Prescriptions (STOPP), as well as the Beers criteria and the Good Palliative-Geriatric Practice (GPGP) algorithm.
The START and STOPP criteria, as their names indicate, are tools that can help doctors determine which medicines are better to start with older patients and which medications in their regimens they should cease taking. The Beers criteria, from the American Geriatric Society, puts medications into five categories, including inappropriate medications for people over 50 and medications that may be inappropriate given a person's renal function. The GPGP guides patients and prescribers through a series of questions that can help determine whether a drug should be stopped, whether the patient should be shifted to another drug, whether a dosage should be reduced, or whether the patient can continue on the drug.
"None of these are tools that take away the decision-making of a clinician -- they are there to act as guides to help us rethink how we're prescribing," Cocohoba said. "All of these tools, Beers, START, STOPP, are to give you pause to make you think about whether or not they are appropriate in your patient and make those decisions on an individual patient level."
Given the rates of polypharmacy and the potentially damaging effects of being on so many active agents, Cocohoba did suggest that, when appropriate, prescribers should speak to their patients about potentially switching to a two-drug HIV regimen, like dolutegravir and rilpivirine or dolutegravir and lamivudine.
Attendees at Cocohoba's talk did say that some patients, as well as some medical professionals, had some reservations about switching to two-drug regimens. Cocohoba responded that any regimen choice is ultimately up to the patient and that a patient can always try a new regimen and switch back if it doesn't work.
"There's a lot to talk about with our patients. We want to make sure everyone is happy with the outcome and everyone is aligned with the same goals, and that there's follow-up monitoring to make sure that everybody is as healthy as possible," Cocohoba said. She also pointed out that there are more two-drug regimens pending approval by the Food and Drug Administration. "Two drugs are going to be sort of a hot-button topic as a treatment approach for the next several years."
When it comes to reducing polypharmacy, Cocohoba emphasized that prescribers must have a conversation with their patients about each pill that they are taking, including over-the-counter medications. That means weighing the risks, benefits, and side effects of each pill. She recalled that she even showed patients studies that showed that multivitamins don't reduce mortality in people with HIV.
"Ultimately, they are the decision maker," she said. "Some of them are really attached to their multivitamins. It's about checking in with patients about what they want."
Cocohoba recommended motivational interviewing and using open-ended questions that get patients to talk about how each medication makes them feel, both physically and psychologically. She also recommended an online tool, Deprescribing, to help providers.
"The key to solving, if we can ever solve, polypharmacy, is all about relationships," Cocohoba said toward the end of her session. "It's really about the communication you have with a patient and, if you are not the primary prescriber, your relationship with the prescriber. To really collaborate in ways where we can recognize medications that may not be necessary and have appropriate dialogue with the right persons to make sure we are moving forward on a path that is as safe and with the medications that the patient needs -- and maybe less or none of the medications the patient does not need."