Managing the HIV-infected adult patient in the emergency department

As highly active antiretroviral therapies have advanced, HIV patients who are treatment-adherent can achieve undetectable viral loads, virtual elimination of opportunistic infection, improved quality of life, and normal life expectancy. This issue focuses on emergency department management of HIV patients both with successful disease suppression from long-term therapy as well as the patient with low CD4 counts in the context of lack of engagement with care, nonadherence, or undiagnosed disease. Optimal emergency department management of patients with HIV also includes identifying and treating undiagnosed patients, helping to re-establish care for those who have been lost to followup, and preventing new HIV infections with pre-exposure and postexposure prophylaxis.

Management of hepatitis B and C infections in rheumatologic disease

Hepatitis B and C viruses present dual considerations in rheumatic disease as both etiologic factors and important comorbidities that must be assessed and addressed. This review summarizes the link between hepatitis B and arthritis and polyarteritis nodosa as well as hepatitis C and arthritis, Sicca syndrome and cryoglobulinemic vasculitis. Recent data pertaining to the antiviral management in these conditions, especially regarding the use of the direct-acting antivirals in hepatitis C, are also presented. Additionally, guidance on testing and treatment of hepatitis B and C as comorbidities in the context of systemic inflammatory rheumatic conditions and the use of disease-modifying antirheumatic therapy are discussed.

Older HIV-infected adults. Complex patients (III): Polypharmacy

Polypharmacy is a well-described problem in the geriatric population. It is a relatively new problem for people living with HIV (PLWH), as this group now has a life expectancy approaching that of the general population. Defining polypharmacy for PLWH is difficult, since the most common traditional definition of at least five medications would encompass a large percentage of PLWH who are on antiretrovirals (ARVs) and medications for other medical comorbidities. Even when excluding ARVs, the prevalence of polypharmacy in PLWH is higher than the general population, and not just in resource-rich countries. Using a more nuanced approach with "appropriate" or "safer" polypharmacy allows for a better framework for discussing how to mitigate the associated risks. Some of the consequences of polypharmacy include adverse effects of medications including the risk of geriatric syndromes, drug-drug interactions, decreased adherence, and over- and undertreatment of medical comorbidities. Interventions to combat polypharmacy include decreasing pill burden-specifically with fixed-dose combination (FDC) tablets- and medication reconciliation/deprescription using established criteria. The goal of these interventions is to decrease drug interactions and improve quality of life and outcomes. Some special populations of interest within the community of PLWH include those with chronic pain, substance abuse, or requiring end of life care. A final look into the future of antiretroviral therapy (ART) shows the promise of possible two-drug regimens, which can help reduce the above risks of polypharmacy.

HIV/HCV Antiviral Drug Interactions in the Era of Direct-acting Antivirals

Therapy for human immunodeficiency virus (HIV) and chronic hepatitis C has evolved over the past decade, resulting in better control of infection and clinical outcomes; however, drug-drug interactions remain a significant hazard. Joint recommendations from the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America regarding drug-drug interactions between HIV antiretroviral agents and direct-acting antiviral agents for treatment of hepatitis C virus (HCV) infection are reviewed here. This review is oriented to facilitate appropriate selection of an antiviral therapy regimen for HCV infection based on the choice of antiretroviral therapy being administered and, if necessary, switching antiretroviral regimens.

Prevalence and Risk Factors for Clinically Significant Drug Interactions with Antiretroviral Therapy

STUDY OBJECTIVES

To identify the prevalence and types of clinically significant drug interactions (CSDIs) in the drug regimens of patients with human immunodeficiency virus (HIV) infection who were receiving antiretroviral therapy, and to explore risk factors for these CSDIs.

DESIGN

Retrospective medical record review.

SETTING

Academic HIV specialty clinic.

PATIENTS

One hundred fifty-three randomly selected patients with HIV infection who were receiving antiretroviral therapy from May 1-September 30, 2006.

MEASUREMENTS AND MAIN RESULTS

Data were collected on patient demographics, date of HIV diagnosis, most recent viral load and CD4(+) count, Centers for Disease Control and Prevention HIV classification, and comorbid conditions. Patients' drug regimens were analyzed for total and clinically significant antiretroviral drug interactions using three resources. Logistic regression and classification and regression tree analysis were used to identify independent CSDI predictors. Clinically significant drug interactions were defined as drug interactions that required a dosage adjustment or consisted of a drug combination that is contraindicated due to its high potential for clinical adverse effects. Of the 153 patients, at least one CSDI was found in 41.2% of their regimens: 34.6% with at least one drug interaction that required a dosage adjustment, 2.0% with at least one contraindicated drug combination, and 4.6% with at least one of each of these CSDIs. In the logistic regression model, risk factors independently associated with CSDIs were age older than 42 years (odds ratio [OR] 2.9, 95% CI 1.2-7.1), more than three comorbid conditions (OR 3.0, 95% CI 1.4-6.6), treatment with more than three antiretroviral agents (OR 2.4, 95% CI 1.0-5.8), and treatment with a protease inhibitor (OR 11.5, 95% CI 4.2-31.2). When directly compared, CSDIs were more prevalent among protease inhibitor-based than nonnucleoside reverse transcriptase inhibitor-based regimens (p<0.001).

CONCLUSION

Clinically significant drug interactions are highly prevalent among HIV-infected patients receiving antiretroviral therapy. Knowledge of the risk factors for CSDIs may help clinicians recognize and manage CSDIs.

Community pharmacy Target Intervention Program to improve aspirin use in persons with diabetes

OBJECTIVE

To identify the rate of aspirin or antiplatelet/anticoagulant use in persons with diabetes presenting to community pharmacies and determine whether a student pharmacist-driven Target Intervention Program (TIP) could increase the number of eligible persons with diabetes receiving aspirin therapy in accordance with American Diabetes Association (ADA) recommendations.

DESIGN

Unblinded, single intervention.

SETTING

Eight Community Pharmacy Advanced Practice Experience (CPAPE) sites in New York State.

PARTICIPANTS

Persons having prescriptions filled for diabetes medications or supplies who were not receiving antiplatelet/anticoagulant medications.

INTERVENTIONS

Assessment sheets were completed by student pharmacists for eligible patients to determine appropriateness for aspirin therapy. Recommendations for aspirin therapy were faxed to physicians when indicated, and physicians responded via fax for aspirin therapy implementation. The student pharmacists contacted patients, informed patients of physician decisions, and provided appropriate counseling.

MAIN OUTCOME MEASURES

Number of persons with diabetes currently receiving aspirin or antiplatelet/anticoagulant medications and the number initiated on aspirin as a result of the TIP.

RESULTS

A total of 436 persons with diabetes were identified. Of those contacted, 322 agreed to participate and 31 declined; 228 were taking aspirin or other antiplatelet/anticoagulant agents at baseline. Students completed assessment sheets, which were forwarded to physicians, for 79 subjects potentially eligible to receive aspirin therapy; 65 physician responses were received (82% response rate). Aspirin therapy was initiated in 53 patients (67%).

CONCLUSION

The TIP enabled CPAPE students to increase aspirin use among eligible persons with diabetes in accordance with ADA guidelines.

Use of Ultrasonography-Assisted Liposuction for the Treatment of Human Immunodeficiency Virus--Associated Enlargement of the Dorsocervical Fat Pad

Enlargement of the dorsocervical fat pad (i.e., "buffalo hump") is one manifestation of the lipodystrophy syndrome associated with human immunodeficiency virus. We report our experience with the use of ultrasonography-assisted liposuction in a cohort of 10 patients with this complication.

Drug interactions associated with HAART: focus on treatments for addiction and recreational drugs

The advent of HAART has improved survival in patients infected with HIV; however, treatment is complicated by potential drug interactions. The risk of drug interactions is compounded by the use of additional therapies for comorbid conditions, such as substance abuse, and by the use of recreational drugs. HIV health care providers should be aware of the potential interaction of recreational drugs and addiction treatments with HAART because of the potential for significant adverse effects for their HIV-infected patients. This article provides a review of the literature on drug interactions among addiction therapies, recreational drugs, and HAART.

Update on prescribing errors with HAART

Medication-prescribing errors associated with HAART may lead to treatment failure, development of resistance, or drug toxicity. Reports have described HAART-related medication-prescribing errors; the causes of these errors are often multifactorial and include lack of knowledge about HIV treatments, complexity of regimens, and sound-alike/look-alike names of medications. Clinicians caring for HIV-infected patients should be aware of the potential for prescribing errors associated with HAART and employ strategies to prevent them.

Improving aspirin prophylaxis in a primary care diabetic population

STUDY OBJECTIVE

To evaluate and improve adherence to American Diabetes Association guidelines for prophylactic aspirin therapy in ambulatory patients with diabetes using a pharmacy-directed intervention.

DESIGN

Unblinded, single intervention.

SETTING

Rural, primary care clinic.

SUBJECTS

Eighty-five patients with a diagnosis of diabetes mellitus.

INTERVENTION

Patients with diabetes were identified from database searches and routine clinic visits. Medical records were screened for aspirin use, allergies, adverse events, and contraindications. During routine clinic visits or structured telephone interviews, patients with indications for aspirin therapy were advised to begin enteric-coated aspirin 81 mg/day A follow-up survey assessed adherence.

MEASUREMENTS AND MAIN RESULTS

At baseline, 28 (33%) of 85 patients were receiving aspirin therapy An additional 8 patients had contraindications to aspirin, and 2 patients had no indications for aspirin therapy Aspirin was recommended to 27 patients during clinic interventions and to 15 patients during telephone interventions. Two patients declined the recommendation. At the completion of this intervention, 70 (82%) of 85 patients were receiving daily aspirin or had accepted the recommendation to begin therapy.

CONCLUSIONS

A pharmacy-directed intervention increased prophylactic aspirin therapy in patients with diabetes from 33% of patients at baseline to 82% at the end of the study The intervention, which has a simple, patient-focused design, serves as a template for improving aspirin prophylaxis among patients with diabetes in other ambulatory settings.

Case report. Hepatitis B virus and HIV coinfection

Coinfection with HIV and hepatitis B virus (HBV) is more common than that with HIV and hepatitis C virus (HCV), although more attention has been given to HCV coinfection as a result of its higher frequency of chronic disease. Natural history studies with HIV-HCV coinfection have also shown more rapid progression of liver disease, and end-stage liver disease due to hepatitis C is now a leading cause of death in HIV-infected patients. Like HCV infection, HBV infection can also be associated with significant morbidity and mortality in patients with HIV infection. Fortunately, treatment options of hepatitis B are expanding and may have a clinical impact on slowing disease progression. A case study of a patient with severe HBV-HIV coinfection is presented to illustrate what is known about this increasingly problematic disease state.

An assessment of herbal therapy use, adherence and utilization of pharmacy services in HIV clinics

OBJECTIVE

To assess herbal therapy use, adherence to antiretroviral therapy (ART) and pharmacy service utilization in two HIV clinics using a prospective questionnaire-based assessment.

RESULTS

Seventy-six patients completed the questionnaire. Twenty-six patients (34%) reported using at least one herbal therapy; 14 (54%) reported this to their provider. Providers correctly predicted herbal therapy use in 10 (38%) patients reporting herbal therapy use. Seventy-three patients (96%) reported a high level of adherence (> 90%), while only 37% had a viral load < 80 copies/ml. Clinic and community-based pharmacy services were underutilized.

CONCLUSIONS

Herbal therapy use was common, under-reported and difficult for providers to predict. Unreported herbal therapy use could lead to virologic failure as a result of unknown drug-herb interactions. Consultative pharmacy services in the clinic and retail pharmacies are underutilized.