Abstract and Introduction
Objectives: Polypharmacy in people living with HIV (PLWH) increases the risks of medicine-related problems (events or circumstances involving drug therapy that actually or potentially interfere with desired health outcomes). We aimed to examine the feasibility and acceptability of a Medicines Management Optimisation Review (MOR) toolkit in HIV outpatients.
Methods: This was a multi-centre randomized controlled study across four HIV centres. In all, 200 PLWH on combination antiretroviral therapy, either > 50 years old or < 50 years with other comorbidities, were enrolled to have a MOR or received standard pharmaceutical care. The primary outcome was the difference in the number of medicine-related problems (MRPs) between intervention and standard care groups at baseline and 6 months. Acceptability, cost of the intervention and health-related quality of life were also examined.
Results: In all, 164 patients were analysed: 70 in the intervention group and 94 in the standard care group. A significant number of MRPs were detected in those patients receiving MOR compared with the standard care group at baseline (93 vs. 2; p = 0.001, z = −8.6, r = 0.6) and 6 months (33 vs. 3; p = 0.001, z = −5.7, r = 0.4). A significant reduction in the number of new MRPs at 6 months in the intervention group versus baseline was also observed (p = 0.001, Z = −3.7, r = 0.2); 44% of MRPs were fully resolved at baseline and 51% at 6 months. No changes in health-related quality of life following MOR or between MOR and standard care groups were observed. The MORs were highly acceptable among patients and healthcare professionals.
Conclusions: The MOR toolkit was feasible and acceptable, suggesting that HIV outpatient services might consider implementing MOR for targeted populations under their care.
The introduction of combination antiretroviral therapy (cART) has transformed HIV disease from a life-threatening illness into a chronic condition with near-normal life expectancy, with the majority of people living with HIV (PLWH) in the UK expected to be over 50 years of age by 2025. The synergistic effects of HIV and ageing predispose patients to higher levels of comorbidities at younger ages compared with the general population. Consequently, polypharmacy and medicine-related problems (MRPs) are an important challenge facing older PLWH and their care providers.[3–5] In the general population, older age, multiple comorbidities and polypharmacy are significantly associated with adverse drug events, drug–drug interactions (DDIs) and low adherence to medications. Medicine-related problems also cause greater healthcare resource utilisation, leading to significantly higher healthcare costs. Older PLWH are at particular risk of MRPs because on average they have more comorbidities and are prescribed more medicines than those who are younger or than people who are HIV-negative.[8,9] Moreover, treatment of PLWH with cART is complex, with significant propensity for MRPs. Medicine-related problems, where medicines are either prescribed inappropriately, or the intended benefits are not realized have also been identified globally as significant contributory factors to medicine-related harm,[11,12] with higher prevalence of preventable medication harm observed in older people.
There is extensive evidence in older people with multimorbidity that medicines optimization, including structured medicine (or medication) reviews (SMRs), contributes to reducing the incidence of MRPs.[14–17] Availability of complete medicines lists has been shown to reduce number of DDIs per HIV outpatient, and a specialist pharmacist consultation prior to routine HIV outpatient appointments has been shown to increase detection of potential DDIs. Hence medication reviews are one of the medicines optimization tools recommended to reduce the risk of DDIs and other MRPs in PLWH. However, despite the well-documented higher prevalence of DDIs and polypharmacy in PLWH, evidence of the benefits of medication reviews in the HIV outpatient setting is lacking.
We aimed to examine the feasibility and acceptability of a MOR toolkit and the impact of the intervention on health-related quality of life and costs.