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Torres TS, Jesus JS, Arabe D, Guaraldo L, Lessa FS, Facchinetti LD, Estrela R, Veloso VG, Grinsztejn B, Cardoso SW. Frailty and health-related quality of life among older people living with HIV pre- and post-COVID-19 pandemic onset: A cross-sectional study. Braz J Infect Dis 2024; 28:103723. [PMID: 38369295 PMCID: PMC10904252 DOI: 10.1016/j.bjid.2024.103723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 12/30/2023] [Accepted: 01/24/2024] [Indexed: 02/20/2024] Open
Abstract
INTRODUCTION Antiretroviral therapy increased the survival and life expectancy of People living With HIV (PWH). Frailty-related syndromes among older PWH (aged 50+ years) may affect their Health-related Quality of Life (HQoL). Additionally, the COVID-19 pandemic has impacted health-related outcomes. This study aimed to estimate the prevalence of frailty and pre-frailty among older PWH, and to explore associations of HQoL with the study assessment period and frailty status. METHODS Cross-sectional study conducted pre- (23-Mar-2019 to 5-Mar-2020) and post-COVID-19 pandemic onset (23-Jun-2021 to 5-May-2022), among older PWH at INI-Fiocruz, the largest cohort of PWH in Rio de Janeiro, Brazil. We measured frailty using Fried assessment, consisting of five domains: unintentional weight loss; self-reported exhaustion, weakness, slow walking speed, low physical activity. HQoL was assessed using the ACTG SF-21, which contains 21 questions divided into 8 domains. We used Chi-Square test, Fisher's exact test, Kruskal-Wallis and ranksum test for comparisons. RESULTS We included 250 older PWH: 109 (43.6 %) pre- and 141 (56.4 %) post-COVID-19 pandemic onset. Median age was 60-years (IQR: 55‒64). Most self-identified as cisgender men 152 (60.8 %), Pardo/Black 146 (58.4 %), with completed secondary education or less 181 (72.7 %) and low income 132 (52.8 %). Overall, prevalence of frailty and pre-frailty were 9.2 % (95 % CI: 8.1‒10.3) and 61.6 % (95 % CI: 54.0‒69.2). Prevalence of frailty in the pre- and pos-COVID-19 pandemic periods were 7.3 % and 10.6 % (p = 0.66). HQoL scores were lower among participants with frailty compared to those with non-frailty and pre-frailty in all eight domains, and among those included in the post-COVID-19 compared to pre-COVID-19 period for four domains. CONCLUSIONS We observed low prevalence of frailty, but high prevalence of pre-frailty among older PWH. Frailty status did not differ according to the COVID-19 assessment period. Assessment of frailty and HQoL should be incorporated in clinical practice for older PWH. Programs to reverse or prevent frailty should be implemented within the public health system.
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Affiliation(s)
- Thiago S Torres
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (INI-Fiocruz), Rio de Janeiro, RJ, Brazil.
| | - Jovanice S Jesus
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (INI-Fiocruz), Rio de Janeiro, RJ, Brazil
| | - Daniel Arabe
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (INI-Fiocruz), Rio de Janeiro, RJ, Brazil
| | - Lusiele Guaraldo
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (INI-Fiocruz), Rio de Janeiro, RJ, Brazil
| | - Flavia Serrao Lessa
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (INI-Fiocruz), Rio de Janeiro, RJ, Brazil
| | - Lívia Dumont Facchinetti
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (INI-Fiocruz), Rio de Janeiro, RJ, Brazil
| | - Rita Estrela
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (INI-Fiocruz), Rio de Janeiro, RJ, Brazil
| | - Valdilea G Veloso
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (INI-Fiocruz), Rio de Janeiro, RJ, Brazil
| | - Beatriz Grinsztejn
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (INI-Fiocruz), Rio de Janeiro, RJ, Brazil
| | - Sandra W Cardoso
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (INI-Fiocruz), Rio de Janeiro, RJ, Brazil
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Toledo T, Castro T, Oliveira VG, Veloso VG, Grinsztejn B, Cardoso SW, Torres TS, Estrela R. Pharmacokinetics of Antiretroviral Drugs in Older People Living with HIV: A Systematic Review. Clin Pharmacokinet 2023; 62:1219-1230. [PMID: 37561283 DOI: 10.1007/s40262-023-01291-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/20/2023] [Indexed: 08/11/2023]
Abstract
BACKGROUND AND OBJECTIVE The life expectancy of people living with HIV (PLWHIV) has significantly improved in recent decades, mostly due to antiretroviral (ARV) therapy. Aging can affect the pharmacokinetics of drugs and, as a consequence, increase the risk of drug interactions and toxicity that may impact treatment. The aim of this study was to carry out a systematic review of the literature on the effect of aging on ARV pharmacokinetics. METHODS Searches were performed in the BVS, EMBASE and PUBMED databases until November 2022. All studies available in English, Spanish and Portuguese investigating the pharmacokinetics of ARV approved by the US Food and Drug Administration (FDA) from 2005 to 2020 were selected. Peer-reviewed publications were included if they met all criteria: adults (≥ 18 years of age) living with or without HIV; report any pharmacokinetic parameter or plasma concentration of at least one of the following ARVs: tenofovir alafenamide fumarate (TAF); doravirine (DOR), rilpivirine (RIL) and etravirine (ETR); darunavir (DRV), tipranavir (TPV) and fostemsavir (FTR); dolutegravir (DTG), raltegravir (RAL), bictegravir (BIC) and elvitegravir (EVG); maraviroc (MVC); ibalizumab (IBA); cobicistat (COBI). Pharmacokinetic parameters were reported stratified per age group: young adults (aged 18-49 years) or older (age ≥ 50 years) and all studies were evaluated for quality. The review protocol was registered in the PROSPERO database (registration number CRD42021236432). RESULTS Among 97 studies included, 20 reported pharmacokinetic evaluation in older individuals (age ≥ 50 years). Twenty five percent of the articles were phase I randomized clinical trials with HIV-negative participants and non-compartmental pharmacokinetic analysis presenting the parameters area under the curve (AUC) and peak drug concentration (Cmax). Seven age-stratified studies evaluated BIC, ETR, DRV, DTG, DOR and RAL. We found publications with discordant results for ETR and DTG pharmacokinetics in different age groups. DRV exposure was highly variable but modestly increased in aging PLWHIV. In contrast, no influence of age on BIC, DOR and RAL exposure was observed. A variability in pharmacokinetic parameters could be observed for the other ARVs (TAF and MVC) in different age groups. CONCLUSION Exposure to DRV increases modestly with age, while exposure to BIC, DOR and RAL appears to be unaffected by age. As the available evidence to confirm a potential effect of aging on ARV pharmacokinetics is limited, further studies are necessary.
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Affiliation(s)
- Thainá Toledo
- Sérgio Arouca National School of Public Health, ENSP Fiocruz, Rio de Janeiro, RJ, Brazil
| | - Thales Castro
- Evandro Chagas National Institute of Infectious Diseases, INI Fiocruz, Rio de Janeiro, Brazil
| | - Vanessa G Oliveira
- Evandro Chagas National Institute of Infectious Diseases, INI Fiocruz, Rio de Janeiro, Brazil
| | | | - Beatriz Grinsztejn
- Evandro Chagas National Institute of Infectious Diseases, INI Fiocruz, Rio de Janeiro, Brazil
| | - Sandra Wagner Cardoso
- Evandro Chagas National Institute of Infectious Diseases, INI Fiocruz, Rio de Janeiro, Brazil
| | - Thiago S Torres
- Evandro Chagas National Institute of Infectious Diseases, INI Fiocruz, Rio de Janeiro, Brazil
| | - Rita Estrela
- Sérgio Arouca National School of Public Health, ENSP Fiocruz, Rio de Janeiro, RJ, Brazil.
- Evandro Chagas National Institute of Infectious Diseases, INI Fiocruz, Rio de Janeiro, Brazil.
- Faculty of Pharmacy, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil.
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da Silva RPN, Marins LMS, Guaraldo L, Luz PM, Cardoso SW, Moreira RI, Oliveira VDG, Veloso VG, Grinsztejn B, Estrela R, Torres TS. Pharmacotherapeutic profile, polypharmacy and its associated factors in a cohort of people living with HIV in Brazil. AIDS Res Ther 2023; 20:57. [PMID: 37605195 PMCID: PMC10440883 DOI: 10.1186/s12981-023-00548-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 07/18/2023] [Indexed: 08/23/2023] Open
Abstract
BACKGROUND The increased survival provided by the access, development, and evolution of antiretroviral drugs (ARV) greatly increased the life expectancy of people living with HIV (PWH). This has also led to an increased occurrence of diseases or morbidities related to aging. In individuals with multiple comorbidities, the simultaneous use of multiple medications, also known as polypharmacy, is common, and rational use of medications is essential. This study aims to describe the pharmacotherapeutic profile, estimate the prevalence of polypharmacy and identify factors associated with polypharmacy in a cohort of adult PWH from a referral unit in Rio de Janeiro, Brazil. METHODS Cross-sectional study including PWH on ARV who received at least one medical prescription (outpatient/hospitalized) in 2019. We described the proportion of prescribed medications according to ARV and Anatomical Therapeutic Chemical (ATC) classes stratified by age (< 50 vs. ≥50 years). Polypharmacy was defined as ≥ 5 medications prescribed beyond ARV. Logistic regression models assessed demographic and clinical factors associated with polypharmacy. RESULTS A total of 143,306 prescriptions of 4547 PWH were analyzed. Median age was 44.4 years (IQR:35.4-54.1) and 1615 (35.6%) were ≥ 50 years. A total of 2958 (65.1%) participants self-identified as cisgender man, 1365 (30.0%) as cisgender woman, and 224 (4.9%) as transgender women. Most self-declared Black/Pardo (2582; 65.1%) and 1984 (44.0%) completed elementary education or less. Median time since HIV diagnosis was 10.9 years (IQR:6.2-17.7). Most frequently prescribed concomitant medications were nervous system (64.8%), antiinfectives for systemic use (60.0%), alimentary tract and metabolism (45.9%), cardiovascular system (40.0%) and respiratory system (37.1%). Prevalence of polypharmacy was 50.6% (95%CI: 49.2-52.1). Model results indicated that being older, self-identify as cisgender woman, having less education and longer time since HIV diagnosis increased the odds of polypharmacy. CONCLUSIONS We found high rates of polypharmacy and concomitant medication use in a cohort of PWH in Brazil. Targeted interventions should be prioritized to prevent interactions and improve treatment, especially among individuals using central nervous system and cardiovascular medications, as well as certain groups such as cisgender women, older individuals and those with lower education. Standardized protocols for continuous review of patients' therapeutic regimens should be implemented.
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Affiliation(s)
- Robson Pierre Nascimento da Silva
- Laboratório de Pesquisa Clínica em DST/AIDS, Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (INI-Fiocruz), Rio de Janeiro, Brazil
| | - Luana M S Marins
- Laboratório de Pesquisa Clínica em DST/AIDS, Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (INI-Fiocruz), Rio de Janeiro, Brazil
| | - Lusiele Guaraldo
- Laboratório de Pesquisa Clínica em Doenças Febris Agudas, Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (INI-Fiocruz), Rio de Janeiro, Brazil
| | - Paula Mendes Luz
- Laboratório de Pesquisa Clínica em DST/AIDS, Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (INI-Fiocruz), Rio de Janeiro, Brazil
| | - Sandra W Cardoso
- Laboratório de Pesquisa Clínica em DST/AIDS, Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (INI-Fiocruz), Rio de Janeiro, Brazil
| | - Ronaldo I Moreira
- Laboratório de Pesquisa Clínica em DST/AIDS, Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (INI-Fiocruz), Rio de Janeiro, Brazil
| | - Vanessa da Gama Oliveira
- Serviço de Farmácia (Sefarm), Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (INI-Fiocruz), Rio de Janeiro, Brazil
| | - Valdilea G Veloso
- Laboratório de Pesquisa Clínica em DST/AIDS, Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (INI-Fiocruz), Rio de Janeiro, Brazil
| | - Beatriz Grinsztejn
- Laboratório de Pesquisa Clínica em DST/AIDS, Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (INI-Fiocruz), Rio de Janeiro, Brazil
| | - Rita Estrela
- Laboratório de Pesquisa Clínica em DST/AIDS, Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (INI-Fiocruz), Rio de Janeiro, Brazil
- Laboratório de Farmacometria, Faculdade de Farmácia, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil
| | - Thiago S Torres
- Laboratório de Pesquisa Clínica em DST/AIDS, Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (INI-Fiocruz), Rio de Janeiro, Brazil.
- , Av Brasil 4365 Manguinhos, 21045-360, Rio de Janeiro, Brazil.
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Cattani VB, Jalil EM, Eksterman L, Torres T, Wagner Cardoso S, Castro CRV, Monteiro L, Wilson E, Bushman L, Anderson P, Veloso VG, Grinsztejn B, Estrela R. Estradiol and Spironolactone Plasma Pharmacokinetics Among Brazilian Transgender Women Using HIV Pre-Exposure Prophylaxis: Analysis of Potential Interactions. Clin Pharmacokinet 2023; 62:1031-1041. [PMID: 37261664 PMCID: PMC10338392 DOI: 10.1007/s40262-023-01248-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2023] [Indexed: 06/02/2023]
Abstract
BACKGROUND AND OBJECTIVE An important barrier to HIV prevention among transgender women (TGW) is the concern that oral pre-exposure prophylaxis (PrEP) negatively affects the efficacy of feminizing hormone therapy (FHT). We aimed to assess the impact of PrEP on FHT pharmacokinetics (PK) among TGW from Brazil. METHODS We performed a drug-drug interaction sub-study among TGW enrolled in a daily oral PrEP demonstration study (PrEParadas, NCT03220152). Participants had a first PK assessment (PK1) 15 days after FHT (estradiol valerate 2-6 mg plus spironolactone 100-200 mg) initiation and then started PrEP (tenofovir disoproxil fumarate 300 mg/emtricitabine 200 mg). A second PK evaluation was performed 12 weeks later (PK2). Blood samples were collected prior and after the directly observed dosing (0, 0.5, 1, 2, 4, 6, 8, and 24 hours). Pharmacokinetic parameters of estradiol, spironolactone, and metabolites were estimated by non-compartmental analysis (Monolix 2021R2, Lixoft®) and compared as geometric mean ratios (GMRs, 90% confidence interval [CI]). RESULTS Among 19 TGW who completed the substudy, median age was 26 years (interquartile range: 23-27.5). Estradiol area under the plasma concentration-time curve (AUCτ) and trough concentrations did not differ between PK1 and PK2 evaluations (GMR [90% CI]: 0.89 [0.76-1.04] and 1.06 [0.94-1.20], respectively). Spironolactone and canrenone AUCτ were statistically lower at PK2 than PK1 (0.76 [0.65-0.89] and 0.85 [0.78-0.94], respectively). Canrenone maximum concentration was also lower at PK2 than PK1 (0.82 [0.74-0.91]). CONCLUSION Estradiol PK was not influenced by PrEP concomitant use. The small differences observed in some spironolactone and canrenone PK parameters should not prevent the concomitant use of estradiol-based FHT and PrEP. TRIAL REGISTRATION This trial (NCT03220152) was registered on July 18, 2017.
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Affiliation(s)
- Vitória Berg Cattani
- Evandro Chagas National Institute of Infectious Diseases INI Fiocruz, Rio de Janeiro, Brazil.
| | - Emilia Moreira Jalil
- Evandro Chagas National Institute of Infectious Diseases INI Fiocruz, Rio de Janeiro, Brazil
| | - Leonardo Eksterman
- Evandro Chagas National Institute of Infectious Diseases INI Fiocruz, Rio de Janeiro, Brazil
| | - Thiago Torres
- Evandro Chagas National Institute of Infectious Diseases INI Fiocruz, Rio de Janeiro, Brazil
| | - Sandra Wagner Cardoso
- Evandro Chagas National Institute of Infectious Diseases INI Fiocruz, Rio de Janeiro, Brazil
| | - Cristiane R V Castro
- Evandro Chagas National Institute of Infectious Diseases INI Fiocruz, Rio de Janeiro, Brazil
| | - Laylla Monteiro
- Evandro Chagas National Institute of Infectious Diseases INI Fiocruz, Rio de Janeiro, Brazil
| | - Erin Wilson
- University of California, San Francisco, USA
| | | | | | | | - Beatriz Grinsztejn
- Evandro Chagas National Institute of Infectious Diseases INI Fiocruz, Rio de Janeiro, Brazil
| | - Rita Estrela
- Evandro Chagas National Institute of Infectious Diseases INI Fiocruz, Rio de Janeiro, Brazil.
- Faculty of Pharmacy, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil.
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Cattani VB, Jalil EM, Eksterman L, Torres T, Cardoso SW, Castro CRV, Monteiro L, Wilson E, Bushman L, Anderson P, Veloso VG, Grinsztejn B, Estrela R. Impact of feminizing hormone therapy on tenofovir and emtricitabine plasma pharmacokinetics: a nested drug-drug interaction study in a cohort of Brazilian transgender women using HIV pre-exposure prophylaxis. J Antimicrob Chemother 2022; 77:2729-2736. [PMID: 35815666 PMCID: PMC9525093 DOI: 10.1093/jac/dkac229] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 06/16/2022] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES Potential interactions between feminizing hormone therapy (FHT) and pre-exposure prophylaxis (PrEP) may be a barrier to PrEP use among transgender women (TGW). We aimed to assess the impact of FHT on PrEP plasma pharmacokinetics (PK) among TGW. METHODS This was a PK substudy of the effects of FHT on tenofovir disoproxil fumarate/emtricitabine nested to a trans-specific PrEP demonstration study (NCT03220152). Participants were assigned to receive PrEP only (noFHT) or standardized FHT (sFHT; oestradiol valerate 2-6 mg plus spironolactone 100-300 mg) plus PrEP for 12 weeks, after which they could start any FHT (aFHT). Short- and long-term PK assessment occurred at Weeks 12 and 30-48, respectively (plasma samples prior and 0.5, 1, 2, 4, 6, 8 and 24 h after dose). Non-compartmental PK parameters of tenofovir and emtricitabine were compared as geometric mean ratios (GMRs) between noFHT and PrEP and FHT (sFHT at short-term PK; aFHT at long-term PK) participants. RESULTS No differences in tenofovir and emtricitabine plasma PK parameters were observed between the short-term PK of noFHT (n = 12) and sFHT participants (n = 18), except for emtricitabine Cmax [GMR: 1.15 (95% CI: 1.01-1.32)], or between noFHT short-term PK and aFHT long-term PK (n = 13). Most participants were on oestradiol valerate 2 mg at the short-term PK (56%) and 4 mg at the long-term PK (54%). Median (IQR) oestradiol levels were 56.8 (43.2-65.4) pg/mL at short-term PK (sFHT) and 44.8 (24.70-57.30) pg/mL at long-term PK (aFHT). No participants in this analysis seroconverted during the study. CONCLUSIONS Our results indicate no interaction of FHT on tenofovir levels, further supporting PrEP use among TGW using FHT.
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Affiliation(s)
- Vitória Berg Cattani
- Evandro Chagas National Institute of Infectious Diseases INI Fiocruz, Rio de Janeiro, Brazil
| | - Emilia Moreira Jalil
- Evandro Chagas National Institute of Infectious Diseases INI Fiocruz, Rio de Janeiro, Brazil
| | - Leonardo Eksterman
- Evandro Chagas National Institute of Infectious Diseases INI Fiocruz, Rio de Janeiro, Brazil
| | - Thiago Torres
- Evandro Chagas National Institute of Infectious Diseases INI Fiocruz, Rio de Janeiro, Brazil
| | - Sandra Wagner Cardoso
- Evandro Chagas National Institute of Infectious Diseases INI Fiocruz, Rio de Janeiro, Brazil
| | - Cristiane R V Castro
- Evandro Chagas National Institute of Infectious Diseases INI Fiocruz, Rio de Janeiro, Brazil
| | - Laylla Monteiro
- Evandro Chagas National Institute of Infectious Diseases INI Fiocruz, Rio de Janeiro, Brazil
| | - Erin Wilson
- University of California, San Francisco, USA
| | | | | | | | - Beatriz Grinsztejn
- Evandro Chagas National Institute of Infectious Diseases INI Fiocruz, Rio de Janeiro, Brazil
| | - Rita Estrela
- Evandro Chagas National Institute of Infectious Diseases INI Fiocruz, Rio de Janeiro, Brazil
- Faculty of Pharmacy, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
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