Jennifer Edelman from Yale University and colleagues looked at ‘polypharmacy’, or use of multiple drugs for various conditions, amongst people with HIV, as well as the association between polypharmacy and risk of death.
This cross-sectional analysis (October 2009 to September 2010) included 16,989 HIV-positive people on ART and 47,613 matched HIV-negative control subjects in the US Veterans Aging Cohort Study, which maintains extensive electronic medical and pharmacy records. People with no visits in the past year, those with a cancer diagnosis at baseline, those with no dispensed medications, and HIV-positive people not on ART were excluded.
Almost all the participants were men, the average age was about 55 years, 47% were black and 40% were white. In the HIV-positive group, the median CD4 cell count was 322 cells/mm3, 56% were taking protease inhibitors and 44% were on drugs in the non-nucleoside reverse transcriptase inhibitor class (NNRTIs).
People with HIV were taking a median of 3.49 drugs, compared 4.23 for HIV-negative people, counting long-term outpatient medications other than antiretrovirals. HIV-positive people were more likely to be on zero to three drugs (~35% vs ~44%) and about equally likely to be on four to six drugs (~30%), but less likely to be taking seven to nine drugs (~18% vs ~15%), ten to twelve drugs (~8% vs ~5%) or more than twelve drugs (~5% vs ~3%).
Amongst both HIV-positive and HIV-negative people, the most frequent co-morbid conditions were hypertension, diabetes, severe mental illness, substance-use disorders, cardiovascular disease and chronic obstructive pulmonary disease (COPD). All but substance use were more common in the HIV-negative group.
The most frequently used medications (besides antiretrovirals) were lipid-lowering drugs, ACE inhibitors, gastric medications, antidepressants, beta blockers, non-opioid analgesics, calcium channel blockers, diuretics, diabetes drugs and genitourinary medications, all of which were used more often by HIV-negative people.
Being HIV positive, male and black or Hispanic were associated with fewer drugs, whilst having diabetes, COPD, cardiovascular disease or hypertension was associated with more drugs. However, people with kidney disease or liver cirrhosis were on fewer drugs, perhaps because these conditions affect drug processing and can lead to worsened side-effects or interactions.
Use of multiple medications was associated with a higher risk of death for both HIV-positive and HIV-negative people. People taking more than five non-ART drugs had a 30% higher all-cause mortality rate and, for each medication beyond five, mortality rose by 5% in an adjusted analyses. This increase in mortality was greater for people with HIV.
“Treated HIV-infected patients are commonly exposed to polypharmacy”, but “are less likely to be prescribed non-ART medications” than HIV-negative people, the researchers concluded.
“Future studies examining longitudinal associations with polypharmacy and mortality and other health outcomes are warranted,” they recommended. “The development and evaluation of interventions to reduce polypharmacy among HIV-infected patients are needed.”