A high proportion of older people with HIV are taking medicines they do not need that could increase the risk of falls and confusion, Spanish researchers have found in a review of studies looking at inappropriate medication prescribing in people with HIV.
The review, published in the Journal of Acquired Immune Deficiency Syndromes, highlights the importance of regular checks on medications to ensure that prescriptions are appropriate for a person's current medical condition and that some types of medicine used for the treatment of anxiety and depression are not being prescribed beyond their recommended periods.
As the population of people with HIV ages, an increasing number of people with HIV are taking multiple medications for long-term conditions associated with ageing. Some researchers think that ageing in people with HIV is accelerated and that people with HIV begin to enter old age after the age of 50 to 55 years. Not all HIV physicians agree with this point of view, but what’s indisputable is that people with HIV are more likely to develop cardiovascular disease, chronic kidney disease, osteoporosis and non-AIDS-defining cancers than others of a similar age.
The potential for over-prescribing is clear, as in all older people with multiple health conditions. What’s less clear is how many older people with HIV are affected and what proportion are taking medications they don’t need, or which are potentially harmful.
Researchers from the Hospital Universitario Ramón y Cajul, Madrid, carried out a scoping review of studies that had looked at medication burden and inappropriate prescribing in older people with HIV.
They identified 39 studies, mostly European single-centre studies with less than 100 participants that looked at a cross-section of people once.
Three prospective cohort studies which followed people over time looked at the medication burden in older people with HIV. A study which included 122 elderly people with HIV in Switzerland found that 31% were taking at least one potentially inappropriate medication, most commonly benzodiazepines and hypnotics. In the United Kingdom and Ireland, the POPPY study in 699 people with HIV over 50 found that 28% were using anticholinergic drugs including benzodiazepines and the antidepressant citalopram. Use of anticholinergics was associated with an increased risk of falls and frailty. In Spain, a study of 251 older people with HIV found that 20% had a high drug burden and 45% were taking anticholinergic medications or others with sedative effects.
Most of the cross-sectional studies identified by the review focussed on the burden of anticholinergic drugs prescribed to people with HIV. Anticholinergic drugs are used to treat numerous conditions that occur more frequently in older people, including stomach ulcers, chronic obstructive pulmonary disease (COPD), over-active bladder, cystitis and insomnia.
Anticholinergic drugs include tricyclic antidepressants, some antihistamines, antipsychotics and antiepileptics, some SSRI antidepressants (citalopram, escitalopram, paroxetine, fluvoxamine) and some painkillers.
A high burden of anticholinergic drugs is associated with an increased risk of death in older people. They are also associated with a higher risk of neurocognitive impairment and falls in older people and use of multiple drugs can lead to anticholinergic syndrome, in which people develop confusion, agitation and restlessness and may lose balance and coordination.
Studies identified in the review typically reported that around 25%-30% of older people with HIV were taking anticholinergic drugs. The largest cross-sectional study that examined anticholinergic drug use found that 14% of people with HIV over 45 in the Swiss HIV Cohort were taking at least one anticholinergic and 7% were taking an anticholinergic drug with another sedative.
The most frequently over-prescribed drugs identified in this review were benzodiazepines such as lorazepam and diazepam. Prescribed for anxiety and as short-term sleep aids, benzodiazepines are associated with neurocognitive impairment and serious falls in people with HIV. The European AIDS Clinical Society included benzodiazepines in its list of “Top 10 Drug Classes to Avoid in Elderly PLHIV” in 2019.
Studies included in the review also identified drugs that doctors were failing to prescribe, notably statins to prevent cardiovascular disease, and vitamin D and calcium to protect against bone thinning and fractures.
The authors highlight a Spanish “Guide for pharmacological deprescription in HIV patients”, published by physicians in 2021. It encourages doctors to look for medications that can be discontinued in all people with over 50 with a Veterans Aging Cohort score over 25 and taking more than five medications.
The review also identified six studies, including one randomised trial, which evaluated interventions to cut unnecessary prescribing. These included a randomised study in 187 older people with HIV in the United Kingdom, in which participants were assigned to a medication optimisation review with a pharmacist or to existing clinical management. There was a significant reduction in medication-related problems after six months in the intervention group, most commonly drug-drug interactions. A study of 248 people with HIV in the United States, without a control group, found that a medication assessment resulted in the discontinuation of an average of two drugs.
In the United Kingdom, people with long-term conditions, like HIV, people taking multiple medications and older people should receive an annual medication review to check the burden of anticholinergic drugs and other medicines.
The study authors say that as well as tackling over-prescribing by prevention of illness, medication reviews using standardised tools can check whether prescribing is appropriate for individuals and flag up gaps in prescribing.
Many tools exist to screen for inappropriate prescribing. The review identified 23 tools used in 39 studies to detect potentially inappropriate medications. The authors say that tools to identify inappropriate prescribing may need to be adapted for people with HIV.
The review also emphasises the importance of improved awareness of inappropriate prescribing of benzodiazepines (for example, benzodiazepines should only be prescribed for short periods to manage insomnia) and of deprescribing benzodiazepines. Dependency on benzodiazepines can develop after a few weeks, emphasising the need for slow dose reduction along with non-pharmacological support.
Vélez-Diaz-Pallarés M et al. Potentially inappropriate prescribing in older people living with HIV: a scoping review. Journal of Acquired Immune Deficiency Syndromes, 94 (5): 445-60, 2023.