Polypharmacy: What Is It and How Does It Impact People Living With HIV

Segment Description: Jennifer Cocohoba, PharmD, professor of clinical pharmacy at the University of California, San Francisco, summarizes her ANAC 2019 presentation on polypharmacy and how it affects people living with HIV.

Contagion®: What is polypharmacy and how does it affect people living with HIV?

Cocohoba: Polypharmacy is a very common problem in the United States and probably worldwide, at least in developed countries where medication is the mainstay for treatment of chronic disease. Polypharmacy is defined in different ways in different studies, but probably most commonly, polypharmacy is defined as taking a five or more prescription drugs.

Polypharmacy as far as we understand, in the United States, approximately 40% of persons who are of older age typically 65 or older, take at least five prescription drug, that's a pretty high rate of polypharmacy. For persons living with HIV, they also experience polypharmacy at about the same rates, at 30% in different studies and above, sometimes as high as 75%.

But for persons living with HIV, they achieve that number of having five or more prescription drugs faster, because chronic treatment of HIV usually involves at least two, most likely three medications. So you've already hit three out of five at that point and it just adds on from there.

Contagion®: What can be done from a provider standpoint to mitigate the issues that come with polypharmacy?

Cocohoba: From a provider standpoint, I think one of the most important things to do with a patient, whether they're living with HIV or have other chronic diseases, is ensure that we regularly go over their medication list. We want to make sure we start with an accurate base to really understand what a patient is taking. That way we can evaluate not only the quantity of medications, but really more importantly, the quality of the medications that they have been prescribed. And that's not meant in a pejorative kind of way. We're not saying some prescribers are bad by prescribing X, Y, or Z. But really understanding whether or not that medication is needed, absolutely necessary, whether it has good evidence base behind it, whether it's not causing adverse effects, and even whether it's right for that patient at that particular time in their life.

For example, we may more aggressively treat blood pressure in our younger patients that as patients age and they tolerate falls, dizziness, and other adverse effects of blood pressure medicines less, we may deintensify or even stop some of the blood pressure medicines. So, polypharmacy, in addition to evaluating quantity of medications, we should really look at quality and really look at it at that stage of that patient's life and health to ensure that each of their medications is appropriate.

I think that one of the things that we consider as HIV practitioners is the opportunity to reduce polypharmacy via either consolidation of HIV regimens through use of fixed dose combination or single tablet regimens. And I think that's a pretty common practice. Just a reminder for practitioners that that isn't necessarily really improving polypharmacy, because you have the same number of prescription agents, you just have less pills by which you are taking them with. And that's a great thing because it can be helpful for adherence, sometimes financially for patients that have to be copays on these medications, so consolidation is something I think that HIV practitioners have been looking at for a long time. Simplification, often from a 3 plus drug antiretroviral regimen down to a 2 drug regimen is a growing trend in HIV. I think there's a lot of discussion that has to happen around whether or not simplification of an HIV regimen is an appropriate move for a patient.

We have some simplified regimens that may be appropriate for persons who are treatment naive. And then we have some simplification regimens that are FDA approved, for example, dolutegravir-rilpivirine, which may be considered for patients who are stably virally suppressed, and meet other conditions such as are highly adherent and perhaps are not taking proton pump inhibitors, who have access to food for adequate absorption of rilpivirine.

So these regimens that we have dolutegravir plus lamivudine in treatment naive patients and dolutegravir-rilpivirine in treatment experienced patients. I think studies are going to continue to examine other options for 2 drug regimen simplification, which could improve polypharmacy in some of our patients, as long as we select those regimens appropriately, and make sure that they are going to maintain viral suppression.

The origins of polypharmacy don't always lie with the prescriber. I think sometimes we have to consider as healthcare practitioners, that our patients are very attached to some of their medications or just are very used to taking them or have worries or fears about what would happen if they didn't take those medication. So I think an open line of communication and really sensitive dialogue to patient’s health literacy, what they understand about their medication, can open up the lines of communication on whether or not to get rid of therapy, maintain therapy, or adjust therapy in a way that all parties are aligned with.

It’s really important for all health care team members to address polypharmacy. Everyone has really important input about medications that when put together can really help create a comprehensive treatment plan for the patient. So as we know patients talk to their case managers, their social workers, address point of care with their nurses or their pharmacists or their doctors, about the medications that they're taking. So each team member I think has the responsibility of ensuring that a patient is taking the appropriate medications and each team member is responsible for communicating with each other in order to come up with the best medication plan for our patients.