HIV and the Aging Patient: Managing Co-morbidities Heather Free, - - PowerPoint PPT Presentation

▶
hiv and the aging patient managing co morbidities
SMART_READER_LITE
LIVE PREVIEW

HIV and the Aging Patient: Managing Co-morbidities Heather Free, - - PowerPoint PPT Presentation

Jun 14, 2023 616 likes •1.09k views

HIV and the Aging Patient: Managing Co-morbidities Heather Free, PharmD, AAHIVP Objectives Review HIV/AIDS statistics within the United States Define HIV and Aging and life expectancy List treatment issues that are of greater

slide-1
SLIDE 1

HIV and the Aging Patient: Managing Co-morbidities

Heather Free, PharmD, AAHIVP

slide-2
SLIDE 2

Objectives

  • Review HIV/AIDS statistics within the United States
  • Define HIV and Aging and life expectancy
  • List treatment issues that are of greater concern in older

people with HIV

  • Discuss factors that make DDI more complicated in older

people with HIV

Disclosure: I will not discuss non-FDA approved or investigational uses of any products/devices

slide-3
SLIDE 3

Understanding HIV Where You Live

slide-4
SLIDE 4

AIDSVu vs. CDC Stats

slide-5
SLIDE 5

Persons Living with Diagnosed or Undiagnosed HIV Infection HIV Continuum Outcomes by Race/Ethnicity, 2014 – United States

slide-6
SLIDE 6

Persons Living with Diagnosed or Undiagnosed HIV Infection HIV Continuum Outcomes by Transmission Category, 2014 – United States

slide-7
SLIDE 7

Global HIV Response World Health Organization 2000-2015

slide-8
SLIDE 8

HIV Trends per Our World in Data

slide-9
SLIDE 9

Early HAART Regimens Were No Fun……

Morning Afternoon Evening # Pills AZT 6 3TC 2 X3 X3 X3 NFV 9 Total HAART 17 Side Effects: 3 tablets/day 5 tablets/day

25 pills daily!

slide-10
SLIDE 10

Growing Older with HIV

HIV and Aging: what does this mean for the medication cocktail?

slide-11
SLIDE 11

HIV and Aging

  • More and more HIV patients are living longer
  • Aging process is more accelerated in an HIV+ patient vs HIV-

due to increased inflammation

  • Classified at ≥ 50 YO
  • Virally suppressed HIV+ patients are more prone to death

from non-AIDS co-morbidities

Wing, Edward J. HIV and aging. International Journal of Infectious Disease 53 (2006) 61-68.

slide-12
SLIDE 12

AGEhIV: Older HIV-Infected Patients at Increased Risk for Multiple Co-Morbidities

Cross-sectional analysis

  • f co-morbidity

prevalence in prospective cohort study

  • f HIV-Infected patients

(n=540) vs controls (n=524) ≥45 YO

Schouten J, et al. The AGEnIV Cohort Study. Clin Infect Dis. 2014;59:1787-1797.

slide-13
SLIDE 13

AGEhIV Comorbidities

Schouten J, et al. The AGEnIV Cohort Study. Clin Infect Dis. 2014;59:1787-1797.

slide-14
SLIDE 14

Factors Related to Non-AIDS Co-morbidities in HIV-Infected Patients

  • AGING
  • Chronic HIV infection
  • HCV and other coinfections
  • Genetics
  • Obesity, exercise, diet,

smoking

  • Stress
  • Depression
  • Inflammation and

fibrosis

  • Dyslipidemia
  • Insulin resistance
  • Decreased physical

functioning

  • Cardiovascular
  • Renal
  • Metabolic
  • Functional
  • Neuropsychiatric

Warriner AH, et al. Infect Dis Clin North Am. 2014; 28:457-476.

slide-15
SLIDE 15

HIV and Inflammation

  • Hypothesis: HIV infection induces a persistent

inflammatory response, resulting in pathogenic responses and end-organ disease

  • Elevated levels of inflammatory markers associated with

increased risk of non-AIDS co-morbidities and mortality in HIV-infected patients

  • ART partially reduces some inflammatory biomarker levels

1. Tenorio AR, et al. J Infect Dis. 2014;210:1248-1259 2. So-Armah KA, et al. J Acquir Immune Defic Syndr. 2016;72:206-213.

slide-16
SLIDE 16

Inflammation Associated with Disease in Treated HIV Infection

  • Mortality
  • Cardiovascular Disease*
  • Cancer
  • Venous Thromboembolism
  • Type 2 Diabetes
  • Renal Disease
  • Cognitive Dysfunction
  • Depression Functional impairment/frailty*
  • 1. Tenorio AR, et al. J Infect Dis. 2014;210:1248-1259 2. So-Armah KA, et al. J Acquir Immune Defic Syndr. 2016;72:206-213.
slide-17
SLIDE 17

Cardiovascular Disease and HIV

  • HIV+ patients are at increased risk for cardiovascular

disease (CVD), including myocardial infarction (MI) and stroke.

  • Patients with HIV should undergo screening for CV risk

using the ACC/AHA risk calculator

  • Prevention to lower risk of CVD include:
  • Diet
  • Exercise
  • Smoking cessation
  • Evaluation of lipid-lowering agents

(Smart 2006, McComsey 2012, Torriani 2008)

slide-18
SLIDE 18

Screening and Assessing Cardiovascular Risk

  • 10 Year ASCVD Risk: Pooled Cohort Equation
  • Demographics
  • Age (40-79 year), gender and race
  • History
  • HTN, DM, tobacco use
  • Measurements
  • Total Cholesterol, HDL, systolic blood pressure

Goff Jr Et Al. 2013 ACC/AHA guidelines on the assessment of cardiovascular risk: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol.2014; 63:2935-2959.

slide-19
SLIDE 19

ACC/AHA Statin Benefit,

Adapted from Stone NJ et al. 2013 report on the treatment of blood cholesterol to reduce ASCVD in adults. Circulation. 2014; 129:S1-S45.

Yes  Yes  Yes  Yes   No  No  No 

slide-20
SLIDE 20

Statin Selection +ART

PI- or COBI-Containing Regimens

High-Intensity Statins Moderate-Intensity Statins Low-Intensity Statins Atorvastatin 20mg

Atorvastatin 10mg Pravastatin 10-20mg

Rosuvastatin 10-20mg

Rosuvastating 5mg Fluvastatin 20-40mg Pravastatin 40-80mg* Pitavastatin 1mg Pitavastatin 2-4mg

Simvastatin and lovastatin are contraindicated for patients receiving a PI, COBI, and/or RTV

*With darunavir, reduce pravastatin to 20-40mg

Dube MP. Lipid management. 2015. p. 241-255

slide-21
SLIDE 21

Statin Selection +ART, continued

NNRTI-, RAL-, or DTG-Containing Regimens

High-Intensity Statins Moderate-Intensity Statins Low-Intensity Statins Atorvastatin 40-80mg Atorvastating 10-20mg Pravastatin 10-20mg Rosuvastatin 20mg Rosuvastatin 10mg Fluvastatin 20-40mg Pravastatin 40-80mg Pitavastatin 1mg Pitavastatin 2-4mg Lovastatin 20mg Lovastatin 40mg Simvastatin 10mg Simvastatin 20-40mg

Dube MP. Lipid management. 2015. p. 241-255

slide-22
SLIDE 22

ART to Avoid in High Cardiac Risk Patients

  • Consider avoiding ABC- and LPV/r-based regimen
  • Switch Boosted PI to DTG in suppressed patients with High

CV Risk2

  • Hyperlipidemia: Pl/r, AVC, EFB and EVG/c have been

associated with increased serum lipids

  • HTN medications: PI and COBI combos can interfere with

the rhythm of the heart (PR or QTc intervals)

  • Anticoagulants: Aspirin and Heparin no interactions; need

to monitor all other medications for DDI

  • 1. DHHS Guidelines: Antiretroviral Agents for Adults, https://aidsinfo.nih.gov/guidelines
  • 2. Gatell JM, et al. IAS 2017. Abstract TUAB0102. Clinical Trials.gov. NCT02098837.
slide-23
SLIDE 23

Hypertension and HIV

  • Analysis of HTN in HIV infected patients from 1996-2013
  • 1996: 1.68 cases/100 patients
  • 2013: 5.35 cases/100 patients
  • Key risk factors:
  • Age
  • Obesity
  • Diabetes
  • Renal insufficiency
  • Nadir CD4+ cell count < 500 cells/mm3

Okeke NL, et al. Clin Infect Dis. 2016; 63:242-248.

slide-24
SLIDE 24

The Concept of Frailty

  • Multisystem clinical syndrome that reflects biological rather then

chronological age; regarded as the end-stage state1

  • Associated with loss of functional homeostasis, inability to

recover fully after stressors, and morbidity and excess mortality1

  • Risk Factors: Mental Health, Obesity, Arthritis, Viral Hepatitis2
  • 1. Onen NF, et al. J Infect. 2009;59:346-352
  • 2. Erlandson KM, et al. IAS 2011. Abstract TUPE124.
slide-25
SLIDE 25

Frailty Phenotype

Frailty Characteristic Clinical Criteria* Shrinking Unintentional weight loss (>10 lbs) in prior year Muscle weakness Poor grip strength Poor endurance/exhaustion Self-reported exhaustion Slowness Walking time per 15 ft Low activity Low kcal/week expenditure *frailty defined as presence of ≥ 3 criteria; prefrailty as presence of 1-2 criteria

Piggott DA, et al. J Gerontol A Biol Sci Med Sci. 2017;72:389-394

Additional Tools: FRAIL Scale, Clinical Frailty Scale

slide-26
SLIDE 26

Frailty More Common in HIV

  • Assessment of frailty in HIV-infected (n=521) and –uninfected (n=513)

patients in the AGEhIV cohort

Kooij KW , et al. AIDS. 2016;30:241-250.

slide-27
SLIDE 27

Frailty More Common in HIV , continued

  • Assessment of frailty in HIV-infected (n=521) and –uninfected (n=513)

patients in the AGEhIV cohort

Kooij KW , et al. AIDS. 2016;30:241-250.

slide-28
SLIDE 28

Treatment for Frailty

  • There is no treatment
  • Preventative measures:
  • Managing polypharmacy
  • Exercise
  • Nutrition

Willig, AL, et al. The Silent Epidemic - Frailty and Aging with HIV. Total Patient Care HIV HCV. 2016;1(1):6-7.

slide-29
SLIDE 29

Bone Health and HIV

  • Frailty is more prevalent among HIV-infected vs HIV-uninfected

individuals

  • Fracture prevalence and low BMD is common among patients

with HIV

  • Some ART regimens have larger impact on BMD loss than others
  • Backbone: consider FTC/TAF or ABC/3TC vs FTC/TDF
  • Greater BMD loss observed with PI-based vs RAL-based regimens
  • Avoid TDF

DHHS Guidelines: Antiretroviral Agents for Adults, https://aidsinfo.nih.gov/guidelines

slide-30
SLIDE 30

Recommendations for Evaluation of Bone Disease in HIV

HIV-Infected Population Assessment Monitoring Men 40-49 yrs of age Premenopausal women ≥ 40 years of age

  • Assess risk of fragility

fracture using the FRAX

  • For patients with FRAX

score ≤ 10%, monitor FRAX in 2-3 yrs

  • For patients with FRAX

score > 10% perform DXA Men ≥ 50 yrs of age Postmenopausal women Patients with fragility fracture history, receiving chronic glucocorticoids, or high risk of falls

  • Assess BMD using DXA
  • For patients with

advanced osteopenia monitor DXA in 1-2 urs

  • For patients with mild or

moderate osteopenia, monitor DXA in 5 yrs

  • For patients started on

bisphosphonates, repeat DXA in 2 yrs

Brown TT, et al. Clinic Infect Dis. 2015;60:1242-1251.

slide-31
SLIDE 31

Mental Health and HIV

  • What is the cause? HIV or present prior to infection?
  • Which condition takes treatment priority?
  • Mental health medications have many DDI interactions with

ART

  • Mental health must be under control to achieve ART adherence
  • ART regimen determines what mental health medications can

be prescribed

slide-32
SLIDE 32

Syphilis and HIV

  • Syphilis incidence continues to increase within the HIV population
  • HIV-infected patients with syphilis should have a detailed neurologic
  • examination. Abnormal symptoms should undergo cerebrospinal

fluid (CSF) analysis.

  • Test for Neurosyphilis: neurological dysfunction (eyes or ears),
  • Penicillin (IM, IV) is the treatment of choice for syphilis

Workowski, KA, et al. Centers for Disease Control and Prevention. Sexually transmitted disease treatment guidelines, 2015. MMWR 2015;64:1-138.

slide-33
SLIDE 33

HIV + HCV + Opioids

  • Commonality between HIV

, HCV and opioid epidemic

  • Resources:
  • AIDSVu: https://aidsvu.org
  • HEPVu: https://hepvu.org
  • amfAR: http://opioid.amfar.org
  • Indiana HIV outbreak in 2015 linked to IDU
  • Over 140 cases reported that year
slide-34
SLIDE 34

Substance Abuse and HIV

  • COMPLEX!!!!!
  • Substance abuse causative or a cofactor!?!?!?
  • Substance abuse includes, but not limited to:
  • Alcohol, opioids, cocaine/crack, methamphetamine, MDMA

(ecstasy or molly), benzodiazepines, marijuana, ketamine, GHB, anabolic steroids, nitrate inhalants, barbiturates, nicotine, synthetic compounds

slide-35
SLIDE 35

Substance Abuse and HIV , continued

  • Team efforts for patient care
  • Case management
  • Primary care provider
  • Substance abuse prescriber
  • Mental health
  • Pharmacists
  • Must become substance free
slide-36
SLIDE 36

HIV Diagnosis in the Aging

  • HIV diagnosis at age 50 or greater
  • Elderly population on the rise for STDs, HIV is no exception
  • Prioritizing disease state management
  • Initiating ART is different based on the aging of the body
  • Polypharmacy is real!
slide-37
SLIDE 37

DHHS: Initial Selection ART Based on Age-Related Co-morbidity

Scenario Consider Avoiding Recommendation with Considerations CKD (eFGR <60 mL/min)

  • TDF, especially in

RTV-containing regimens

  • TAF (if eGFR > 30 mL/min)
  • ABC/3TC (HLA-B 5701 negative; 3TC need dose

adjustment for CrCL < 50 mL/min)

  • DRV/RTV + RAL (VL < 100,000 copies/mL

and CD4+ > 200 cells/mm3)

  • LPV/RTV + 3TC (3TC need dose adjustment for

CrCL < 50 mL/min)

Osteoporosis

  • TDF
  • TAF
  • ABC/3TC (HLA-B 5701 negative)

CVD risk

  • ABC

Hyperlipidemia

  • PI/RTV or

PI/COBI

  • EVG/COBI
  • DTG
  • RAL
  • TDF
slide-38
SLIDE 38

Pharmacists Managing HIV: Unlimited Potential

Role Outcomes Patient/caregiver educators Improved adherence to Medication Medication manager/Polypharmacy Improved CD4+ and VL Provision of adherence reminder device Patients more engaged Synchronization of medications Cost savings Coordination of refills Decreased # visits to PCP/hospital Care plans/action plans/progress notes Pharmacy detective Collaborative practice protocols Point of care testing + link to care

slide-39
SLIDE 39

Stigma and HIV

  • Very present and interferes with care/adherence
  • Still believed it is a MSM disease
  • Empower through HIV education
  • Know how to prevent and know your status!
slide-40
SLIDE 40

PrEP

  • Game changer with stigma, depression and life style for

HIV population

  • Who should be on it?
  • Men vs Women on PrEP
  • Should children or young adults take PrEP
  • What about our seniors?
slide-41
SLIDE 41

Is There a Chance for HIV Cure?

slide-42
SLIDE 42

Keeping Healthy HIV Patients Healthy

  • Adhere to HIV mediations
  • Quit smoking
  • Refine diet and maintain normal weight
  • Exercise
  • Reduce alcohol intake; avoid recreational drugs
  • 1. Hermsdorff HH, et all. Endocrine. 2009;36:445-451.
  • 2. Bonato M, et al. BMC Infect Dis. 2017;17:61.
slide-43
SLIDE 43

ART Tips for Older Pts

  • ART is recommended for EVERYONE regardless of CD4

count

  • Organ functions must be closely monitored
  • Polypharmacy more likely to occur
  • Collaboration between healthcare providers is important
  • Focus: education, prevention and care

DHHS Guidelines: Antiretroviral Agents for Adults, https://aidsinfo.nih.gov/guidelines

slide-44
SLIDE 44

Questions? Thank you for your time!