Influence of treatment complexity on adherence and incidence of blips in HIV/HCV coinfected patients

Accelerated aging in people living with HIV: The neuroimmune feedback model

People living with HIV (PLWH) experience earlier onset of aging-related comorbidities compared to their counterparts without HIV. This paper lays out a theoretical model to explain why PLWH experience accelerated aging. Briefly, the model is structured as follows. PLWH experience disproportionately heavy burdens of psychosocial stress across the life course. This psychosocial stress increases risks for depressive symptoms and problematic substance use. Depressive symptoms and problematic substance use interfere with long-term adherence to antiretroviral therapy (ART). Lower ART adherence, in turn, exacerbates the elevated systemic inflammation stemming from HIV infection. This inflammation increases risks for aging-related comorbidities. Systemic inflammation also reduces connectivity in the brain's central executive network (CEN), a large-scale brain network that is critical for coping with stressful circumstances. This reduced capacity for coping with stress leads to further increases in depressive symptoms and problematic substance use. Together, these changes form a neuroimmune feedback loop that amplifies the impact of psychosocial stress on aging-related comorbidities. In this paper, I review the existing evidence relevant to this model and highlight directions for future research.

Barriers and facilitators to maintaining a high level of polypharmacy adherence in people living with HIV: A scoping review

Objectives: With the prolongation of life span and increasing incidence of comorbidities, polypharmacy has become a challenge for people living with HIV/AIDS (PLWH). This review aimed to identify barriers and facilitators to maintaining a high level of polypharmacy adherence in people living with HIV/AIDS. Methods: Nine electronic databases were searched for studies from 1996 to October 2021. Studies were included if they were conducted with adults living with HIV/AIDS and reported barriers and facilitators to maintaining a high level of polypharmacy adherence. This review presents a conceptual framework model to help understand the barriers and facilitators. Results: Twenty-nine studies were included. The majority of publications were observational studies. Eighty specific factors were identified and further divided into five categories, including individual factors, treatment-related factors, condition-related factors, healthcare provider-related factors, and socioeconomic factors, based on the multidimensional adherence model (MAM). Conclusion: Eighty factors associated with polypharmacy adherence among people living with HIV/AIDS were identified and grouped into five major categories. Healthcare providers can make decisions based on the five categories of relevant factors described in this paper when developing interventions to enhance polypharmacy adherence. It is recommended that medications be evaluated separately and that an overall medication evaluation be conducted at the same time to prevent inappropriate polypharmacy use.

Potentially inappropriate prescriptions and therapeutic complexity in older HIV patients with comorbidities

BACKGROUND

The prolonged current survival of human immunodeficiency virus (HIV) patients exposes them to new problems arising from the comorbidities they face.

OBJECTIVES

To describe the situation of comorbidities, polypharmacy, therapeutic complexity and adherence in people living with HIV over 65 years of age and to assess the presence of potentially inappropriate prescriptions (PIP) by applying deprescription criteria.

METHODS

Observational study including HIV people (> 65 years) from a university tertiary level hospital. Demographic, clinical and pharmacotherapeutic characteristics of the patients and their treatments were studied. The prevalence of polypharmacy (> 5 medications) and the pharmacotherapy complexity, quantified by the Medication Regimen Complexity Index (MRCI), were calculated. Therapeutic adherence was assessed by the Simplified Medication Adherence Questionnaire (SMAQ) and the medication possession ratio, according to prescription dispensing records. The Screening Tool of Older People's Prescriptions (STOPP) and List of Evidence-baSed depreScribing for CHRONic patients (LESS-CHRON) criteria were applied to identify PIP.

MAIN OUTCOME MEASURE

PIP in elderly people living with HIV.

RESULTS

Thirty patients were included, 73% of whom were men, with a median age of 71 years (IQR 67 - 76) and a median duration of infection of 17 years (IQR, 9 - 21). Seventy percent of the patients suffered from dyslipemia, 66.7% from hypertension, 43.3% from diabetes and 26.7% from mental health disorders. Seventy percent of the patients took more than 5 medications and 30% more than 10. The MRCI of concomitant medications was higher (18.3 points) than the MRCI of antiretroviral therapy (5.1 points), 66.7% of the studied population was classified as adherent. Finally, 70% of the patients present some PIP according to the STOPP or LESS-CHRON criteria. The polypharmacy was significantly associated (p = 0.008) with meeting deprescription criteria.

CONCLUSION

The elderly people living with HIV present numerous comorbidities and met the criteria for polypharmacy. Their pharmacotherapy complexity is mainly determined by the concomitant treatments. There is a high prevalence of meeting deprescription criteria in people living with HIV over the age of 65 and a clear relationship between polypharmacy and deprescription. The optimization of pharmacotherapy is necessary in this population.

Therapeutic burden in interstitial lung disease: Lessons to learn

BACKGROUND AND OBJECTIVE

Patients with interstitial lung disease (ILD) are often prescribed disease-targeted and symptomatic therapies, both of which can cause significant treatment burden due to polypharmacy and drug-disease interactions. This study aimed to evaluate medication regimen complexity before and after introduction of ILD-specific therapies. Potential drug-disease interactions were evaluated for patients who were prescribed prednisolone.

METHODS

In this study, 214 patients with ILD were assessed for demographic information, co-morbidities and medication use. Medication lists were reviewed prior to and after the introduction of ILD-specific therapies. Complexity of treatment regimen was examined using the validated Medication Regimen Complexity Index (MRCI).

RESULTS

Of the 214 patients, 75 had idiopathic pulmonary fibrosis (IPF) while the rest had inflammatory ILD (chronic hypersensitivity pneumonitis: 45; connective tissue disease-related ILD: 41). Polypharmacy was common at baseline (IPF: 51%, inflammatory ILD: 63%). Following introduction of ILD-specific therapies, median total MRCI scores significantly increased from 8 (interquartile range (IQR) = 8-15) to 22.5 (17.5-27.5) and 14.5 (8.5-21) to 21.5 (16-30) for IPF and inflammatory ILD groups, respectively (P < 0.0001 for both). Complex dosing instructions contributed the most to total MRCI scores for ILD-specific therapies. Among patients receiving prednisolone (n = 113), 88% had ≥1 co-morbidity which may be impacted. Common co-morbidities included gastrointestinal diseases (56%), obesity (37%), osteoporosis (24%) and diabetes mellitus (18%).

CONCLUSION

Polypharmacy and complex medication regimen are common in patients with ILD of different aetiologies. There is a high frequency of potential drug-disease interactions among patients who are prescribed systemic corticosteroids. These findings highlight the need for careful evaluation of the impact of therapeutic complexity and burden in patients with ILD.

Association between medication regimen complexity and pharmacotherapy adherence: a systematic review

PURPOSE

The purpose of this study was to systematically review evidence regarding the association between regimen complexity and adherence.

METHODS

Articles were searched in MEDLINE, LILACS, Cochrane, CINAHL, PsycINFO and references of included studies. Search terms included medication regimen complexity, medication adherence and their synonyms. Randomized clinical trials, cross-sectional, cohort or case-control studies published until March 2016 in English, Portuguese or Spanish were eligible if quantitatively examined the association between complexity and adherence in patients of any age and sex, under any type of medication therapy. Complexity was defined according to the strategy used to assess it in the individual studies. All types of instruments used to assess complexity and adherence were considered. Data extraction was performed using an electronic spreadsheet. Quality assessment was conducted independently using standard scales. The data were qualitatively synthesized.

RESULTS

Fifty-four studies were included: 37 cross-sectional and 17 cohorts. Most were conducted in outpatient setting. Most frequently, studies were carried out with HIV-infected individuals or patients with chronic conditions. The most frequent methods used to assess complexity and adherence were complexity index (19) and self-report (27), respectively. Complexity was associated with adherence in 35 studies. Most of them (28) identified that participants with more complex regimens were less likely to adhere to pharmacotherapy; seven studies found a direct correlation. The others found inconclusive results or no association between complexity and adherence. The studies had low to moderate-methodological quality.

CONCLUSION

Although there was variability regarding the association between complexity and adherence, most studies showed that an increased regimen complexity reduces medication adherence.