Deprescribing of non-antiretroviral therapy in HIV-infected patients.

PURPOSE: In recent decades, the life expectancy of HIV-infected patients has increased considerably, to the extent that the disease can now be considered chronic. In this context of progressive aging, HIV-infected persons have a greater prevalence of comorbid conditions. Consequently, they usually take more non-antiretroviral drugs, and their drug therapy are more complex. This supposes a greater risk of drug interactions, of hospitalization, falls, and death. In the last years, deprescribing has gained attention as a means to rationalize medication use. METHODS: Review of the different therapeutic approach that includes optimization of polypharmacy and control and reduction of potentially inappropriate prescription. RESULTS: There are several protocols for systematizing the deprescribing process. The most widely used tool is the Medication Regimen Complexity Index, an index validated in HIV-infected persons. Anticholinergic medications are the agents that have been most associated with major adverse effects so, various scales have been employed to measure it. Other tools should be employed to detect and prevent the use of potentially inappropriate drugs. Prioritization of candidates should be based, among others, on drugs that should always be avoided and drugs with no justified indication. CONCLUSIONS: The deprescribing process shared by professionals and patients definitively would improve management of treatment in this population. Because polypharmacy in HIV-infected patients show that a considerable percentage of patients could be candidates for deprescribing, we must understand the importance of deprescribing and that HIV-infected persons should be a priority group. This process would be highly feasible and effective in HIV-infected persons.

Economic impact of optimising antiretroviral treatment in human immunodeficiency virus-infected adults with suppressed viral load in Spain, by implementing the grade A-1 evidence recommendations of the 2015 GESIDA/National AIDS Plan. / Impacto económico asociado a la implementación de las recomendaciones con grado de evidencia A-I del documento de consenso de GeSIDA/PNS (2015) relativas a la optimización del tratamiento antirretroviral en adultos infectados por virus de la inmunodeficiencia humana con carga viral suprimida en España.

INTRODUCTION: The objective of this study is to estimate the economic impact associated with the optimisation of triple antiretroviral treatment (ART) in patients with undetectable viral load according to the recommendations from the GeSIDA/PNS (2015) Consensus and their applicability in the Spanish clinical practice. METHODS: A pharmacoeconomic model was developed based on data from a National Hospital Prescription Survey on ART (2014) and the A-I evidence recommendations for the optimisation of ART from the GeSIDA/PNS (2015) consensus. The optimisation model took into account the willingness to optimise a particular regimen and other assumptions, and the results were validated by an expert panel in HIV infection (Infectious Disease Specialists and Hospital Pharmacists). The analysis was conducted from the NHS perspective, considering the annual wholesale price and accounting for deductions stated in the RD-Law 8/2010 and the VAT. RESULTS: The expert panel selected six optimisation strategies, and estimated that 10,863 (13.4%) of the 80,859 patients in Spain currently on triple ART, would be candidates to optimise their ART, leading to savings of €15.9M/year (2.4% of total triple ART drug cost). The most feasible strategies (>40% of patients candidates for optimisation, n=4,556) would be optimisations to ATV/r+3TC therapy. These would produce savings between €653 and €4,797 per patient per year depending on baseline triple ART. CONCLUSION: Implementation of the main optimisation strategies recommended in the GeSIDA/PNS (2015) Consensus into Spanish clinical practice would lead to considerable savings, especially those based in dual therapy with ATV/r+3TC, thus contributing to the control of pharmaceutical expenditure and NHS sustainability.

Development of a risk stratification model for pharmaceutical care in HIV patients.

BACKGROUND: The increasing number of HIV-patients and their complexity makes it necessary to develop risk classification tools to improve the optimization of resources. OBJECTIVE: To design a risk-stratified model for pharmaceutical care (PC) in HIV-patients. METHODS: A cross-sectional, multicenter study. An expert panel was created by Hospital Pharmacist experienced in PC for HIV-patients. The study was designed in 4 phases. The first phase included a review of literature and the development of a summary of the scientific evidence available. According to their score, patients were stratified into three levels of PC. In the second and third phases, a sample of patients was assessed and data information was recorded. The overall analysis also allowed pharmacists to define the actions to be applied at each level of priority.Finally, each stratification model was applied to a new sample of patients to verify their applicability and usefulness. Results: All variables included in the model were weighted in terms of their relative relevance compared to the rest. A sample of 215 patients was evaluated to obtain their score and distribution: Priority-1: score ≥ 32 and 10% of the sample; Priority-2: 18-31.9 and 30%; Priority-3: ≤ 17 and 60%. The PC interventions corresponding to each level of priority were classified into "pharmacotherapeutic monitoring", "training, education and patient tracking" and "coordination of all the healthcare team members". CONCLUSIONS: This study supported the design and adaptation of a selection and stratification model for PC in HIV-patients as a tool to identify those who may benefit from priority intervention.

Antecedentes: El aumento del número de pacientes VIH+ en las consultas de atención farmacéutica (AF) y de su complejidad implica la necesidad de desarrollar herramientas de estratificación para mejorar la optimización de recursos.Objetivo: Diseñar un modelo de estratificación en atención farmacéutica al paciente VIH+.Métodos: Estudio multicéntrico trasversal llevado a cabo por un panel de experto en Farmacia Hospitalaria con experiencia en AF al paciente VIH+. El estudio consta de 4 fases. En primer lugar, se realizó una revisión de la literatura y un resumen de la evidencia científica hasta la fecha estableciendo 3 niveles de estratificación. En las fases 2 y 3 una muestra de pacientes fue analizada para definir las intervenciones específicas de cada nivel de estratificación.Finalmente, se empleó el modelo de estratificación en una nueva muestra de pacientes para comprobar su utilidad y correcta aplicación.Resultados: Las variables incluidas en el modelo fueron ponderadas en función de su relevancia. Se analizaron 215 pacientes con el nuevo modelo obteniéndose una puntuación y distribución como sigue: Prioridad-1: puntuación ≥32 y 10% de la muestra; Prioridad-2: 18-31.9 y 30%; Prioridad-3: ≤17 y 60%. Las diferentes intervenciones de cada nivel se clasificaron en "seguimiento farmacoterapéutico", "entrenamiento y formación de pacientes" y coordinación con el resto del equipo multidisciplinar".Conclusión: Este el primer modelo de estratificación para la atención farmacéutica al paciente VIH+. Su uso permitirá identificar aquellos pacientes que más se podrán beneficiar de cada tipo de intervención.