Highly active antiretroviral
therapy (ART) and its widespread availability have revolutionized the landscape
of HIV care and patient outcomes, transforming infection with HIV into a
manageable chronic condition rather than a life-limiting disease.
This
transformation has created an older patient demographic. The effect that older
age has on the outcomes of ART is not completely understood. Limited data are
available in older individuals due to underrepresentation in clinical trials.
To better understand this relationship, we conducted a literature search to
assess the impact of older age on the outcomes of ART in the older HIV-infected
population, including immunologic and virologic outcomes, mortality, disease
progression, toxicity of ART, and pharmacokinetic considerations. In addition,
package inserts of antiretroviral (ARV) medications were reviewed for efficacy,
safety, and pharmacokinetic information pertaining to the older population.
Most studies in older adults (50 yrs or older) demonstrated slower and
blunted CD4 immune recovery but better virologic suppression in response to
ART. Higher rates of mortality and faster disease progression have been
observed in adults 50 years and older, particularly during the first year after
ART initiation. HIV-infected patients aged 50 years and older appear
to be at greater risk for certain ART-associated toxicities including
nephrotoxicity, decline in bone mineral density and bone fracture, symptomatic
peripheral neuropathy, and cardiovascular disease including myocardial
infarction.
The available literature suggests that clinicians should consider
avoiding agents such as tenofovir disoproxil fumarate (TDF) in older patients
with risk factors for renal impairment and/or osteoporosis. If TDF is used in
patients aged 50 years or older, more frequent monitoring should be
considered. Older age was a significant predictor for higher atazanavir
exposure and higher lopinavir trough concentration at 24 weeks.
The
clinical implications of these findings are unknown. It is imperative that
future development of novel ARV drug therapies includes a greater proportion of
older subjects in clinical trials.
Purchase full article at: http://goo.gl/svvEfs
1Department of Pharmacotherapy and Translational
Research, College of Pharmacy, University of Florida, Gainesville, Florida.
Pharmacotherapy. 2015
Dec;35(12):1140-51. doi: 10.1002/phar.1670.
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