The management of polypharmacy in people living with HIV.

Antiretroviral therapy (ART) has modified the prognosis of HIV which has evolved into a chronic condition. People living with HIV (PLWH) are living longer presenting an increased number of comorbidities leading to polypharmacy. Literature on the prevalence, associated factors, drug-drug interactions (DDIs), effects on ART-outcomes, geriatric conditions, and nutritional status together with health-interventions aimed to reduce it is presented in this review. A literature search was conducted on the MEDLINE database for all relevant English- and Spanish-language studies since 2006. Studies providing data of interest were identified and ordered in groups: (i) prevalence and associated factors (n = 37), (ii) DDIs (n = 19), (iii) Effects on ART-outcomes (n = 12), (iv) Effects on health conditions (n = 13), and (V) Health-interventions to assess and/or reduce it (n = 9). Polypharmacy occurs in 9-91% of PLWH (2.6-19.5% affected by severe polypharmacy). Main factors associated with polypharmacy are older age, a higher number of comorbidities, frailty, deteriorated renal function, and previous hospitalizations. DDIs were present in 19.15-84% of cases (1.3-12.2% for the most severe types). Mainly involved non-ART drugs were antihypertensives, statins, antithrombotic agents, corticosteroids, divalent cations, and antiacids. Polypharmacy can affect ART selection, adherence, and outcomes and has been related to some geriatric conditions such as falls, frailty, and poor nutritional status. Potentially prescribing issues are present in up to 87.9% of cases according to the STOPP-START and Beers criteria and some pharmacist-led interventions have been shown to reduce it. Considering these findings, polypharmacy should be considered a clinical concern in this population and treatment-optimization programs are needed to reduce its burden.

Cost-effectiveness analysis of the daily HIV pre-exposure prophylaxis in men who have sex with men in Barcelona.

INTRODUCTION: Pre-Exposure Prophylaxis (PrEP) for HIV prevention has been implemented in several countries. Previous literature has shown that its cost-effectiveness (and, under some specifications, cost-saving character) is dependent on the reduction in price due to generics, the time-horizon and its effectiveness. The intervention has never been studied in Catalonia after the approval of the PrEP, a territory with extensive implementation. METHODS: Economic evaluation of the implementation of HIV pre-exposition prophylaxis using administrative data from Men who have Sex with Men (MSM) who receive the treatment (at the generic price) compared with non-implementation. A deterministic compartmental model and a social perspective with a micro-costing approach over the time horizon 2022-2062 are used. A baseline 86% effectiveness of PrEP is assumed. RESULTS: Daily oral PrEP is found to be cost-saving: discounted savings in costs are attained after 16 years, and after 40 years they reach 81 million euros. In terms of health indicators, 10,322 additional discounted QALYs are generated by the intervention. Results are sensitive to sexual behavioral patterns among MSM, the price of PrEP (reduced if offered on-demand), its effectiveness and the discount rate. CONCLUSIONS: The use and promotion of PrEP in Catalonia is predicted to result in substantial health and monetary benefits because of reductions in HIV infections. Short-term investments in the promotion of PrEP will result in important cost-savings in the long term.

Variability in adherence to rhGH treatment: Socioeconomic causes and effect on children's growth.

BACKGROUND: In children with growth disorders, mean final height is associated to poor adherence to Growth Hormone therapy. The primary goal of this study is to identify patients who do not adhere to GH therapy and determine the influence of adherence in response to the treatment. The role of serum IGF-I and influence of socio-economic factors on the therapeutic adherence will also be evaluated. METHODS: 158 children under treatment with rhGH were included in the study. Age, gender, etiology, Tanner stage, duration of treatment, growth rate, IGF-I serum values, daily dose, and annual rhGH dose data were collected. Adherence to therapy was defined as moderate-to-poor when the patient had taken less than 92% of the prescribed medication. A subgroup of 106 patients completed a questionnaire to assess social and environmental effects. RESULTS: Moderate-to-poor adherence to rhGH treatment was determined in 33.5% of study patients. A decrease in adherence was associated to treatment duration (p=0.001). A significant correlation was determined between adherence and height velocity (p=0.002) and IGF-I (p<0.0001) levels. Adherence rates were associated to the mother's educational level (p=0.007). CONCLUSION: Poor adherence to GH therapy was observed in one-third of study patients, resulting in suboptimal growth. IGF-I levels can be helpful to identify patients with poor adherence to GH medication. Physicians should pay special attention to certain characteristics of the patient and their environment, and encourage desirable therapeutic compliance.

Antiretroviral treatment switch strategies for lowering the costs of antiretroviral therapy in subjects with suppressed HIV-1 viremia in Spain.

BACKGROUND: The current economic recession in European countries has forced governments to design emergency measures to reduce spending on drugs, including antiretroviral therapy (ART). Switching antiretroviral drugs for others that have the same efficacy and safety profile at a lower cost (cost-reduction measures, CRM) could prove to be a valid means of generating savings. METHODS: Descriptive study of prospective consensus-based CRM undertaken in 2011 in a Catalonian hospital HIV unit among patients with prolonged plasma HIV-1 RNA <50 copies/mL. RESULTS: During the study period, we made 673 switches (87.5% more than the previous year), of which 378 (56.2%) were CRM (16% of all patients treated), leading to a savings of €87,410/month. Switching tenofovir/emtricitabine for abacavir/lamivudine was the most common CRM (129, 31.3%), followed by simplification to boosted protease inhibitor monotherapy (bPImono, 102, 26%). The CRM that generated the greatest saving were switching to bPImono (38%), withdrawal or replacement of raltegravir (24%), switching tenofovir/emtricitabine for abacavir/lamivudine (13%), and switching to nevirapine (5%). Cost savings with CRM were slightly higher than those achieved with medication paid for by clinical trial sponsors (€80,333/month) or through discount arrangements (€76,389/month). CONCLUSION: Proactively switching antiretroviral therapy in selected treated patients with sustained virological suppression can generate significant cost savings in pharmacy spending in developed countries. These findings have implications for decision makers in designing safe strategies that maintain HIV-1 suppression at lower costs.

Consumo de plantas medicinales en los pacientes infectados por el virus de la inmunodeficiencia humana. Patrones de uso y factores relacionados / Use of herbal remedies among HIV-infected patients: Patterns and correlates

Background and objective: To evaluate the prevalence and patterns of use of herbal remedies among HIV-infected patients, and to identify potential health risks and correlates associated with the use of these products. Patients and methods: Cross-sectional survey including 1000 HIV-infected outpatients in Barcelona. Participants completed a questionnaire on the use of herbal remedies and other types of complementary treatments within the previous year as well as on sociodemographic and clinical characteristics. Herbal users’ questionnaires were scrutinized for potential adverse effects and drug interactions with antiretroviral treatment. Correlates of use of herbal remedies were evaluated through logistic regression analyses.Results: One third of patients (n=355) had used herbal remedies, but doctors were informed about such a use by only 69 (19.4%) herbal users. Potential health problems were identified in 193 (54.4%) cases. Herbal remedy use was related to a history of ever discussing complementary and alternative medicine use with the physician (OR: 3.12; 95% CI: 2.30-4.23), having a secondary-school or higher education (OR: 2.63; 95% CI: 1.78-3.88), and perception of complementary therapies as effective (OR: 2.28; 95% CI: 1.18-4.41). Other factors were non-Caucasian ethnicity (OR: 1.65; 95% CI: 1.07-2.56) and the presence of non-HIV-related symptoms (OR: 1.68; 95% CI: 1.24-2.28). Conclusions: Herbal remedy use is common among HIV-infected patients. HIV caregivers and patients should be sensitized to potential risks and the use of these remedies should be routinely monitored in clinical practice (AU)

Fundamento y objetivos: Evaluar la prevalencia y los patrones de uso de plantas medicinales en pacientes infectados por el virus de la inmunodeficiencia humana (VIH) e identificar potenciales riesgos para la salud de los pacientes y factores asociados a dicho consumo.Pacientes y método: Estudio transversal en 1.000 pacientes ambulatorios infectados por el VIH en Barcelona. Los participantes completaron un cuestionario sobre su consumo de plantas medicinales y otros tratamientos complementarios durante el año previo, sus características sociodemográficas y clínicas. Las encuestas de los consumidores de plantas medicinales se revisaron para evaluar potenciales toxicidades o interacciones con el tratamiento antirretroviral. Los factores relacionados con el consumo de plantas medicinales se evaluaron mediante análisis de regresión logística. Resultados: Un tercio de los pacientes encuestados (n=355) había consumido plantas medicinales, pero sólo 69 (19,4%) de ellos habían informado a sus médicos de este consumo. Se identificaron riesgos potenciales para la salud de los pacientes en 193 (54,4%) casos. El consumo de plantas medicinales se asoció a una historia de haber comentado esta posibilidad con su médico en alguna ocasión (odds ratio [OR]: 3,12; intervalo de confianza del 95% [IC 95%]: 2,30-4,23), tener un nivel académico secundario o superior (OR: 2,63; IC 95%: 1,78-3,88), con la percepción de los tratamientos complementarios como efectivos (OR: 2,28; IC 95%: 1,18-4,41), la raza no caucásica (OR: 1,65; IC 95%: 1,07-2,56) y la presencia de síntomas no asociados con el VIH (OR: 1,68; IC 95%: 1,24-2,28).Conclusiones: El consumo de plantas medicinales es frecuente en los pacientes infectados por el VIH. Médicos y pacientes deben concienciarse de los potenciales riesgos que entraña este consumo, que debería ser monitorizado en la práctica clínica (AU)

[Use of herbal remedies among HIV-infected patients: patterns and correlates]. / Consumo de plantas medicinales en los pacientes infectados por el virus de la inmunodeficiencia humana. Patrones de uso y factores relacionados.

BACKGROUND AND OBJECTIVE: To evaluate the prevalence and patterns of use of herbal remedies among HIV-infected patients, and to identify potential health risks and correlates associated with the use of these products. PATIENTS AND METHODS: Cross-sectional survey including 1000 HIV-infected outpatients in Barcelona. Participants completed a questionnaire on the use of herbal remedies and other types of complementary treatments within the previous year as well as on sociodemographic and clinical characteristics. Herbal users' questionnaires were scrutinized for potential adverse effects and drug interactions with antiretroviral treatment. Correlates of use of herbal remedies were evaluated through logistic regression analyses. RESULTS: One third of patients (n=355) had used herbal remedies, but doctors were informed about such a use by only 69 (19.4%) herbal users. Potential health problems were identified in 193 (54.4%) cases. Herbal remedy use was related to a history of ever discussing complementary and alternative medicine use with the physician (OR: 3.12; 95% CI: 2.30-4.23), having a secondary-school or higher education (OR: 2.63; 95% CI: 1.78-3.88), and perception of complementary therapies as effective (OR: 2.28; 95% CI: 1.18-4.41). Other factors were non-Caucasian ethnicity (OR: 1.65; 95% CI: 1.07-2.56) and the presence of non-HIV-related symptoms (OR: 1.68; 95% CI: 1.24-2.28). CONCLUSIONS: Herbal remedy use is common among HIV-infected patients. HIV caregivers and patients should be sensitized to potential risks and the use of these remedies should be routinely monitored in clinical practice.

Actuación del servicio de farmacia en la puesta en marcha del protocolo de Profilaxis antimicrobiana quirúrgica (revisión del primer año) / Management of a pharmacy service in the establishment of a surgical antimicrobiology prophylaxis protocol (review of the first year)

Se analiza el número y el tipo de las intervenciones farmacéuticas realizadas al incorporar al farmacéutico clínico en el circuito de validación de la prescripción de las profilaxis antimicrobiana quirúrgica, protocolizada como dosis única a administrar en la inducción anestésica.En el primer año se realizaron 148 intervenciones farmacéuticas previas al envío de la medicación que fueron bien aceptadas por los clínicos, como colaboración al incremento de la calidad de la profilaxis administrada (AU)