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Polypharmacy in PWH
Avoiding the Pitfalls of Polypharmacy in Older Persons With HIV

Released: October 12, 2020

Expiration: October 11, 2021

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When I asked my patient’s mother to bring me everything, she really did bring me everything. It filled 2 large, colorful shopping bags. There were the plastic pill boxes she filled for her daughter, who has diabetes, schizophrenia, and HIV. There was this month’s big “punch-out” card, provided by her new pharmacy to help with adherence, which was partially punched out to fill the pill boxes. Then there were the bottles—at least 30 of them. Some prescriptions were more than a year old and still had pills left. She looked at me as we spilled everything out on to the table and said, “You can see why I’m feeling a little bit overwhelmed.”

America’s Other Drug Problem
Polypharmacy has been aptly called “America’s other drug problem.” It is estimated that over the next 10 years, polypharmacy will be associated with more than 4.6 million hospitalizations for serious adverse events. Nearly 20% of older persons in the United States take 10 or more prescription and over-the-counter medications. Retrospective cohort studies suggest that polypharmacy may be even more prevalent in older persons with HIV (PWH). When using a cutoff of ≥ 5 non-ARV medications, percentages of PWH and polypharmacy ranged from 34% to 74%.

Not only are these percentages high, the medications themselves can be detrimental. A small cohort study of older PWH in San Francisco found that more than one half had been prescribed a potentially inappropriate medication. In one international study, PWH and polypharmacy were more likely to have poor health outcomes, lower treatment satisfaction, lower overall optimal health, and lower rates of virologic control compared with those without polypharmacy. Not surprising, a study conducted in the VA found a correlation between the number of medications and the risk of hospitalization or death, although this did not differ for persons with or without HIV.

The Burden of Polypharmacy
Adverse events and drug–drug interactions are the obvious harms that can occur with polypharmacy and are likely to be the primary reasons for hospitalizations. Yet, as I was reminded by the mother of the patient I described above, there are also the less tangible impacts of polypharmacy. It is a lot of mental work to keep it all straight. Most medications are taken once or twice daily, and then there are 20 different pills to keep track of plus food requirements, or needing to take pills with a glass of water, or needing to refrigerate insulin, plus trying to fit all of that into a daily schedule full of work or school. It can be overwhelming, to say the least. Adherence devices like pill boxes, watch alarms, and apps are helpful but can only take away some of the work of taking medications.

We also must consider the health system’s issues that contribute to the problem. HIV ARVs are specialty medications: Sometimes they need to be obtained through a specific pharmacy or through mail order, even though the patient’s other medications are available at a local pharmacy. Some medications must be refilled every 90 days, whereas others must be picked up every 30 days. The more medications there are, the greater the day-to-day work of taking them, plus the greater the work associated with just getting those medications home.

Managing Polypharmacy
There is much clinicians can do to support patients and reduce the burdens and harms associated with polypharmacy. At baseline, this requires establishing a complete and accurate medication list by regularly reviewing medications at each visit. This ensures that medications from all sources (primary care providers, specialty care providers, and over the counter) are accounted for when therapeutic decisions are made and that drug interaction screens are complete.

Other Strategies to Reduce the Impact of Polypharmacy

  • Consolidation: Are the patient’s pills available as combination tablets? If so, consider switching, but first consider the financial impact on the patient. Many combination pills are brand name only and may require a higher copay.
  • Simplifying HIV medications: Is the patient a candidate for a simplified regimen? Has he or she been stable on a regimen and virally suppressed with no history of resistance? If clinically appropriate, here is an opportunity to engage in shared decision-making. Discuss the risks and benefits of simplifying therapy.
  • Simplifying non-HIV medications: Can any of the other medications be “deprescribed”? Acid suppression medications are a prime example where daily therapy may no longer be needed.
  • Lowering medication dosages: As persons age, clinicians may reconsider therapeutic targets. For example, is a higher blood pressure (and therefore reduced dosage of antihypertensives) permissible for this patient? Or perhaps a less stringent A1C goal? Such decisions require a patient-centered risk-to-benefit consideration but could reduce adverse events and improve quality of life.
  • Assisting with medication logistics: Can you connect patients to pharmacies that will help them organize their medications? Many pharmacies now offer home or mail delivery or can package medications into blister packs. It can be helpful to connect with the pharmacist to see if medication refill synchronization and automatic refills are available.

My patient’s mother left my office that morning with 3 weeks’ worth of accurately filled pill boxes and a small plastic baggie of as-needed medications. However, I am confident that her load of medications was not the only thing that I lightened that day.

Join the Discussion
What strategies do you regularly use to help patients avoid adverse consequences of polypharmacy? Please share your thoughts in the comments section.

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In your practice, which strategy do you employ most often to help patients avoid being overwhelmed by polypharmacy?
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