User login
PORTLAND—“We are now working with an HIV population that is aging, and along with aging comes a lot of other diseases, such as heart and lung disease, that often result in the use of medications,” began Jennifer Cocohoba, PharmD, AAHIP, Professor of Clinical Pharmacy, UCSF School of Pharmacy. She explained that “the growing problem of having too many medications applies to all, but is particularly important among those living with HIV.”
Polypharmacy, as often defined in research studies, is the taking of at least 5 prescription medications. About 40% of US adults fall into this category, “and it’s not much different for people with HIV,” Cocohoba said. “Persons living with HIV experience polypharmacy at about the same rate.” But people living with HIV may reach that number faster, given that 2 to 3 of the 5 drugs may be for HIV. In addition, those living with HIV are potentially at greater risk for drug interactions.
Quality, not just quantity
Cocohoba explained that it’s important to pay attention to the number of medications a patient is taking because the greater the number, the greater the likelihood of interactions and adverse effects and the more difficult it is for patients to adhere to their medication regimens.
“But we should be looking also at appropriateness of using those medications in a particular person,” she continued, which moves into the realm of quality. She reviewed some criteria that can be used to evaluate the quality of prescribing.
The BEERS Criteria, published by the American Geriatric Society, present classes and specific medications that may be inappropriate in certain elderly persons. Benzodiazepines, for example, commonly used to treat anxiety, are not metabolized as efficiently in the elderly as they are in younger patients. As a result, older adults may experience sedation, falls, or other potentially harmful sequelae. “If a patient age 65 or older is taking a benzodiazepine, that’s a red flag for a clinician to look at that medication and see if it’s really the best choice or whether alternatives might be more appropriate,” explained Cocohoba.
START/STOPP Criteria. Other criteria include the Screening Tool To Alert To Right Treatment (START) and the Screening Tool Of Older People's Prescriptions (STOPP). START focuses on looking for medications that would be appropriate for a particular patient but that are missing from the patient’s medication list, while STOPP focuses on looking for medications that are on the list that might be inappropriate, much like the BEERS Criteria.
The Good Palliative Geriatric Practice Algorithm is a clinical decision-making tool that aids clinicians in thinking through whether a medication is appropriate or inappropriate and whether to maintain, alter, or discontinue the therapy. Cocohoba said it’s often used as a partner to BEERS.
Continue to: Reducing polypharmacy in HIV treatment
Reducing polypharmacy in HIV treatment
Cocohoba explained that there are essentially 2 frameworks for reducing polypharmacy that can be applied to HIV treatment regimens.
Consolidation. With consolidation, the focus is on reducing pill burden—but not by omitting medications. “It’s about looking into simpler dosage forms or combination medications to improve adherence and make life easier,” Cocohoba explained. “Same regimen, fewer pills.”
Simplification, on the other hand, is removing, and thus reducing the number of, agents a patient is taking. The question clinicians should be asking is, according to Cocohoba, “In what situations is it safe to strip down therapy to the bare essentials for the purposes of exposing people to fewer medications, reducing adverse effects, and keeping treatment as manageable as possible to optimize adherence?”
Simplification may be applied to either treatment-naïve or treatment-experienced patients. With the former, clinicians consider, for example, whether patients can be started on HIV treatment consisting of 2 rather than 3 medications. In the latter, “Clinicians may be dealing with patients who are fully virally suppressed on certain regimens and have been for a while; here we see if we can subtract medications, reducing say from triple to double therapy, while maintaining suppression,” explained Cocohoba.
“We want to offer people robust HIV treatment that is going to maintain viral suppression and prevent sequelae of HIV disease,” Cocohoba said, “but we need to balance that with safety, tolerability, and adherence.”
Continue to: An ongoing discussion and multidisciplinary effort
An ongoing discussion and multidisciplinary effort
“Medications can easily pile [up],” Cocohoba said, “so it’s important for clinicians to regularly review medication lists with patients to see if maybe they aren’t using certain agents anymore.” Another reason for clinicians to periodically review medication lists is to make certain they are aware of agents being prescribed by the patient’s other health care providers.
Polypharmacy is the responsibility of everyone on the health care team, both prescribers and nonprescribers, such as social workers and case managers, explained Cocohoba. “If ever there was a health care problem that could use an interdisciplinary approach, polypharmacy is it.”
PORTLAND—“We are now working with an HIV population that is aging, and along with aging comes a lot of other diseases, such as heart and lung disease, that often result in the use of medications,” began Jennifer Cocohoba, PharmD, AAHIP, Professor of Clinical Pharmacy, UCSF School of Pharmacy. She explained that “the growing problem of having too many medications applies to all, but is particularly important among those living with HIV.”
Polypharmacy, as often defined in research studies, is the taking of at least 5 prescription medications. About 40% of US adults fall into this category, “and it’s not much different for people with HIV,” Cocohoba said. “Persons living with HIV experience polypharmacy at about the same rate.” But people living with HIV may reach that number faster, given that 2 to 3 of the 5 drugs may be for HIV. In addition, those living with HIV are potentially at greater risk for drug interactions.
Quality, not just quantity
Cocohoba explained that it’s important to pay attention to the number of medications a patient is taking because the greater the number, the greater the likelihood of interactions and adverse effects and the more difficult it is for patients to adhere to their medication regimens.
“But we should be looking also at appropriateness of using those medications in a particular person,” she continued, which moves into the realm of quality. She reviewed some criteria that can be used to evaluate the quality of prescribing.
The BEERS Criteria, published by the American Geriatric Society, present classes and specific medications that may be inappropriate in certain elderly persons. Benzodiazepines, for example, commonly used to treat anxiety, are not metabolized as efficiently in the elderly as they are in younger patients. As a result, older adults may experience sedation, falls, or other potentially harmful sequelae. “If a patient age 65 or older is taking a benzodiazepine, that’s a red flag for a clinician to look at that medication and see if it’s really the best choice or whether alternatives might be more appropriate,” explained Cocohoba.
START/STOPP Criteria. Other criteria include the Screening Tool To Alert To Right Treatment (START) and the Screening Tool Of Older People's Prescriptions (STOPP). START focuses on looking for medications that would be appropriate for a particular patient but that are missing from the patient’s medication list, while STOPP focuses on looking for medications that are on the list that might be inappropriate, much like the BEERS Criteria.
The Good Palliative Geriatric Practice Algorithm is a clinical decision-making tool that aids clinicians in thinking through whether a medication is appropriate or inappropriate and whether to maintain, alter, or discontinue the therapy. Cocohoba said it’s often used as a partner to BEERS.
Continue to: Reducing polypharmacy in HIV treatment
Reducing polypharmacy in HIV treatment
Cocohoba explained that there are essentially 2 frameworks for reducing polypharmacy that can be applied to HIV treatment regimens.
Consolidation. With consolidation, the focus is on reducing pill burden—but not by omitting medications. “It’s about looking into simpler dosage forms or combination medications to improve adherence and make life easier,” Cocohoba explained. “Same regimen, fewer pills.”
Simplification, on the other hand, is removing, and thus reducing the number of, agents a patient is taking. The question clinicians should be asking is, according to Cocohoba, “In what situations is it safe to strip down therapy to the bare essentials for the purposes of exposing people to fewer medications, reducing adverse effects, and keeping treatment as manageable as possible to optimize adherence?”
Simplification may be applied to either treatment-naïve or treatment-experienced patients. With the former, clinicians consider, for example, whether patients can be started on HIV treatment consisting of 2 rather than 3 medications. In the latter, “Clinicians may be dealing with patients who are fully virally suppressed on certain regimens and have been for a while; here we see if we can subtract medications, reducing say from triple to double therapy, while maintaining suppression,” explained Cocohoba.
“We want to offer people robust HIV treatment that is going to maintain viral suppression and prevent sequelae of HIV disease,” Cocohoba said, “but we need to balance that with safety, tolerability, and adherence.”
Continue to: An ongoing discussion and multidisciplinary effort
An ongoing discussion and multidisciplinary effort
“Medications can easily pile [up],” Cocohoba said, “so it’s important for clinicians to regularly review medication lists with patients to see if maybe they aren’t using certain agents anymore.” Another reason for clinicians to periodically review medication lists is to make certain they are aware of agents being prescribed by the patient’s other health care providers.
Polypharmacy is the responsibility of everyone on the health care team, both prescribers and nonprescribers, such as social workers and case managers, explained Cocohoba. “If ever there was a health care problem that could use an interdisciplinary approach, polypharmacy is it.”
PORTLAND—“We are now working with an HIV population that is aging, and along with aging comes a lot of other diseases, such as heart and lung disease, that often result in the use of medications,” began Jennifer Cocohoba, PharmD, AAHIP, Professor of Clinical Pharmacy, UCSF School of Pharmacy. She explained that “the growing problem of having too many medications applies to all, but is particularly important among those living with HIV.”
Polypharmacy, as often defined in research studies, is the taking of at least 5 prescription medications. About 40% of US adults fall into this category, “and it’s not much different for people with HIV,” Cocohoba said. “Persons living with HIV experience polypharmacy at about the same rate.” But people living with HIV may reach that number faster, given that 2 to 3 of the 5 drugs may be for HIV. In addition, those living with HIV are potentially at greater risk for drug interactions.
Quality, not just quantity
Cocohoba explained that it’s important to pay attention to the number of medications a patient is taking because the greater the number, the greater the likelihood of interactions and adverse effects and the more difficult it is for patients to adhere to their medication regimens.
“But we should be looking also at appropriateness of using those medications in a particular person,” she continued, which moves into the realm of quality. She reviewed some criteria that can be used to evaluate the quality of prescribing.
The BEERS Criteria, published by the American Geriatric Society, present classes and specific medications that may be inappropriate in certain elderly persons. Benzodiazepines, for example, commonly used to treat anxiety, are not metabolized as efficiently in the elderly as they are in younger patients. As a result, older adults may experience sedation, falls, or other potentially harmful sequelae. “If a patient age 65 or older is taking a benzodiazepine, that’s a red flag for a clinician to look at that medication and see if it’s really the best choice or whether alternatives might be more appropriate,” explained Cocohoba.
START/STOPP Criteria. Other criteria include the Screening Tool To Alert To Right Treatment (START) and the Screening Tool Of Older People's Prescriptions (STOPP). START focuses on looking for medications that would be appropriate for a particular patient but that are missing from the patient’s medication list, while STOPP focuses on looking for medications that are on the list that might be inappropriate, much like the BEERS Criteria.
The Good Palliative Geriatric Practice Algorithm is a clinical decision-making tool that aids clinicians in thinking through whether a medication is appropriate or inappropriate and whether to maintain, alter, or discontinue the therapy. Cocohoba said it’s often used as a partner to BEERS.
Continue to: Reducing polypharmacy in HIV treatment
Reducing polypharmacy in HIV treatment
Cocohoba explained that there are essentially 2 frameworks for reducing polypharmacy that can be applied to HIV treatment regimens.
Consolidation. With consolidation, the focus is on reducing pill burden—but not by omitting medications. “It’s about looking into simpler dosage forms or combination medications to improve adherence and make life easier,” Cocohoba explained. “Same regimen, fewer pills.”
Simplification, on the other hand, is removing, and thus reducing the number of, agents a patient is taking. The question clinicians should be asking is, according to Cocohoba, “In what situations is it safe to strip down therapy to the bare essentials for the purposes of exposing people to fewer medications, reducing adverse effects, and keeping treatment as manageable as possible to optimize adherence?”
Simplification may be applied to either treatment-naïve or treatment-experienced patients. With the former, clinicians consider, for example, whether patients can be started on HIV treatment consisting of 2 rather than 3 medications. In the latter, “Clinicians may be dealing with patients who are fully virally suppressed on certain regimens and have been for a while; here we see if we can subtract medications, reducing say from triple to double therapy, while maintaining suppression,” explained Cocohoba.
“We want to offer people robust HIV treatment that is going to maintain viral suppression and prevent sequelae of HIV disease,” Cocohoba said, “but we need to balance that with safety, tolerability, and adherence.”
Continue to: An ongoing discussion and multidisciplinary effort
An ongoing discussion and multidisciplinary effort
“Medications can easily pile [up],” Cocohoba said, “so it’s important for clinicians to regularly review medication lists with patients to see if maybe they aren’t using certain agents anymore.” Another reason for clinicians to periodically review medication lists is to make certain they are aware of agents being prescribed by the patient’s other health care providers.
Polypharmacy is the responsibility of everyone on the health care team, both prescribers and nonprescribers, such as social workers and case managers, explained Cocohoba. “If ever there was a health care problem that could use an interdisciplinary approach, polypharmacy is it.”
Association of Nurses in AIDS Care 2019