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

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 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

Understanding HIV Where You Live

AIDSVu vs. CDC Stats

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

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

Global HIV Response World Health Organization 2000-2015

HIV Trends per Our World in Data

Early HAART Regimens Were No Fun…… Morning Afternoon Evening # Pills AZT 6 3TC 2 X3 NFV 9 X3 X3 Total HAART 17 Side Effects: 25 pills daily! 3 tablets/day 5 tablets/day

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

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.

AGEhIV: Older HIV-Infected Patients at Increased Risk for Multiple Co-Morbidities Cross-sectional analysis of co-morbidity prevalence in prospective cohort study of 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.

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

Factors Related to Non-AIDS Co-morbidities in HIV-Infected Patients • AGING • Chronic HIV infection • Cardiovascular • HCV and other coinfections • Renal • Inflammation and • Genetics • Metabolic fibrosis • Obesity, exercise, diet, • Functional • Dyslipidemia smoking • Neuropsychiatric • Insulin resistance • Stress • Decreased physical • Depression functioning Warriner AH, et al. Infect Dis Clin North Am. 2014; 28:457-476.

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.

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.

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)

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.

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  No  Yes  No  Yes  No  Yes  

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

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

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 Risk 2 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.

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/mm 3  Okeke NL, et al. Clin Infect Dis. 2016; 63:242-248.

The Concept of Frailty Multisystem clinical syndrome that reflects biological rather then  chronological age; regarded as the end-stage state 1 Associated with loss of functional homeostasis, inability to  recover fully after stressors, and morbidity and excess mortality 1 Risk Factors: Mental Health, Obesity, Arthritis, Viral Hepatitis 2  1. Onen NF, et al. J Infect. 2009;59:346-352 2. Erlandson KM, et al. IAS 2011. Abstract TUPE124 .

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 Additional Tools: FRAIL Scale, Clinical Frailty Scale Piggott DA, et al. J Gerontol A Biol Sci Med Sci. 2017;72:389-394

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.

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.

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.

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

Recommendations for Evaluation of Bone Disease in HIV HIV-Infected Population Assessment Monitoring Men 40-49 yrs of age  For patients with FRAX  Assess risk of fragility score ≤ 10%, monitor Premenopausal women ≥ fracture using the FRAX FRAX in 2-3 yrs 40 years of age  For patients with FRAX score > 10% perform DXA Men ≥ 50 yrs of age  For patients with advanced osteopenia Postmenopausal women  Assess BMD using DXA monitor DXA in 1-2 urs  For patients with mild or Patients with fragility moderate osteopenia, fracture history, receiving monitor DXA in 5 yrs chronic glucocorticoids, or  For patients started on high risk of falls bisphosphonates, repeat DXA in 2 yrs Brown TT, et al. Clinic Infect Dis. 2015;60:1242-1251.