Il paziente anziano HIV positivo - Dott.ssa Anna Maria Cattelan UOC Malattie Infettive - Login MSD Salute
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
Il paziente anziano HIV positivo
Dott.ssa
Anna Maria Cattelan
UOC Malattie Infettive
Azienda Ospedaliera di Padova
INFC-1262103-0000-RTG-AV-06/2020
OUTLINE The “aging” HIV-Infected Population • Epidemiological data HIV Geriatrics • Frailty • Comprehensive Geriatric Assessment (CGA) • Comorbidity and polipharmacy Antiretrovirals in the elderly • Antiretroviral guidelines • PK changes • Antiretrovirals pharmakokinetics • Drug-drug interactions
In Italia: Le persone con HIV di età >50 = 41% Le persone con nuova diagnosi di HIV di età >50 =il 21 % Le persone con HIV di età >65 anni sono il 4% ma si stima che saranno il 48% nel 2030 Numero di nuove diagnosi di infezione da HIV per classe di età e per genere (2016)
In Italia: Le persone con HIV di età >50 = 41% Le persone con nuova diagnosi di HIV di età >50 =il 21 % Le persone con HIV di età >65 anni sono il 4% ma si stima che saranno il 48% nel 2030 Numero di nuove diagnosi di infezione da HIV per classe di età e per genere (2016)
Projected Age Distribution of HIV+ Population
Age distribution of HIV+ patients Age distribution of HIV+ patients
On HIV therapy in USA On HIV therapy in the ATHENA cohort
% of pts >50 yrs: 39% (2015) and 74% (2035) % of pts >50 yrs: 30% (2015) and 76% (2035)
Smit M , Lancet ID, 2015
Survival of Older HIV+ Adults in the ART Era
HIV- Controls
1996-2014
HIV+
2006-2014
2000-2005
1996-2000
~9y shorter life expectancy even
among those with no comorbidity
Legarth/Obel, JAIDS, 2016
Accelerated Aging During HIV Infection Pathai et al, J of Gerontology 2014
OUTLINE The “aging” HIV-Infected Population • Epidemiological data HIV Geriatrics • Frailty • Comprehensive Geriatric Assessment (CGA) • Comorbidity and polipharmacy Antiretrovirals in the elderly • Antiretroviral guidelines • PK changes • Antiretrovirals pharmakokinetics • Drug-drug interactions
Grado di autosufficienza?
Con chi vive?
Quali“strumenti”
E’ mai caduto?
Come va la memoria?
devo usare?
E’ triste?
Si sente fiacco?
Cammina bene? Usa il bastone?
Ha appetito? Com’è il peso?
ADL
Fare il BAGNO, VESTIRSI, TOELETTE, SPOSTARSI,
CONTINENZA, ALIMENTAZIONE
IADL
Uso del TELEFONO, SPESA, preparazione CIBO,
governo CASA, BUCATO, MEZZI di TRASPORTO,
FARMACI, DENAROFrailty Related Phenotype • A person can be said to be frail if they have any 3 of the followings: 1. They move slowly 2. They have a weak handgrip 3. They have reduced their level of activity 4. They have (unintentionally) lost weight 5. They feel exhausted • “pre-frail” is used when only one or two of these deficits is present
• effettuare uno screening per fragilità in tutta la popolazione HIV oltre i 50 anni, identificando dapprima i soggetti a rischio e approfondendo poi in questi la valutazione clinica mediante l’applicazione di un Comprehensive Geriatric Assessment (CGA).
Total Patient Care in HIV aging population:
Comprehensive Geriatric Assessment (CGA)
Functional
Patient Status Nutritional
Empowerment Status
Focus on:
* Adverse drug reactions
* Drug-drug interactions
* Non-Adherence
Polypharmacy CGA Comorbidity
Socioeconomic
Neurocognitive
Issues
Disorders
Geriatric
Focus on Social Support:
• Adequacy of Caregiver
Syndromes Focus on:
* Frailty, Falls, Fatigue
• Financial Status * Dementia, Depression,
Delirium, Distress
* OsteoporosisPoly-patology prevalence in cases and controls, stratified
Poly-patology prevalence in cases and controls, stratified
byage
by agecategories
categories
Pp 3.9% 9.0% 20.0% 46.9% Pp 0.5% 1.9% 6.6% 18.7%
Pp 3.9% 9.0% 20.0% 46.9% Pp 0.5% 1.9% 6.6% 18.7%
Pp prevalence was higher in cases than controls in all age strata (all p-valuesOUTLINE The “aging” HIV-Infected Population • Epidemiological data HIV Geriatrics • Frailty • Comprehensive Geriatric Assessment (CGA) • Comorbidity and polipharmacy Antiretrovirals in the elderly • Antiretroviral guidelines • PK changes • Antiretrovirals pharmakokinetics • Drug-drug interactions
La terapia antiretrovirale
nell’anziano
I principi di terapia antiretrovirale nel
paziente anziano sono i medesimi della
popolazione generale e si prefiggono
gli stessi obiettivi viro-immunologiciElementi di specificità del paziente anziano
BODY CHANGES ASSOCIATED WITH AGING
BODY CHANGES ASSOCIATED WITH AGING Decreased albumin increased Vd (albumin-bound drugs) Decreased Pgp activity at blood-brain barrier • Increased [ARV] > efficacy Toornvliet R, et al. Clin Pharmacol Ther 2006; 79: 540-8 • Increased CNS toxicity
Dolutegravir
r = 0.21
• Contrasting data on DTG neuropsychiatric side pCrCl Cutoffs for ARVs
FDA/EMEA Approved for
ARV
Pts With CrCl, mL/min
EVG/COBI/FTC/TDF[1] ≥ 70
DRV/COBI[2] + FTC/TDF*[3] ≥ 70
EFV/FTC/TDF[4] ≥ 50
RPV/FTC/TDF[5] ≥ 50
DTG/ABC/3TC[6] ≥ 50
DRV/RTV, DTG,† or RAL + FTC/TDF*[3] ≥ 50
EVG/COBI/FTC/TAF[7] ≥ 30
RPV/FTC/TAF[8] ≥ 30
DRV/COBI, DRV/RTV, DTG,† or RAL + FTC/TAF[9] ≥ 30
*Recommended FTC/TDF dose in pts with CrCl 30-49 mL/min: 1 tablet q48h.
†Caution needed in INSTI-experienced pts (with certain INSTI-associated resistance
substitutions or clinically suspected INSTI resistance) with severe renal impairment.
RCPDrug Interactions Among ARVs and
Non-ARVs
• Caution needed when using boosters alongside
comedications
No clinically significant interaction expected
Potential interaction that may require close monitoring or dose adjustment
NRTI EI Boosted PI† NNRTI INSTI
Comedication EVG/
Any* MVC ATV DRV LPV EFV ETV NVP RPV DTG RAL
COBI
Beclometasone
Budesonide
Fluticasone
Salmeterol
Amlodipine
*Includes 3TC, ABC, FTC, TAF, TDF, ZDV.
†Includes ATV/RTV, ATV/COBI, DRV/COBI, DRV/RTV, LPV/RTV.
www.hiv-druginteractions.orgEACS Guidelines Version 9.0 October 2017
S.Nozza et al. JAC 2017
ARV therapy in geriatric HIV patients S.Nozza et al. JAC 2017
ARV therapy in geriatric HIV patients
In the triple/mega group
839 patients, there were
113 different ARV regimens
S.Nozza et al. JAC 2017ARV therapy in geriatric HIV patients
In mono/dual therapy for
384 patients, there were 68
In the triple/mega group
different ARV regimens
839 patients, there were
113 different ARV regimens
S.Nozza et al. JAC 2017ARV therapy in geriatric HIV patients
In mono/dual therapy for
384 patients, there were 68
In the triple/mega group
different ARV regimens
839 patients, there were
113 different ARV regimens
High prevalence of non
conventional ARV regimens in
elderly HIV pateinbts suggests
that clinicians try to tailor ARV
regimensaccording to age,
HIV duration, MM and PP
S.Nozza et al. JAC 2017…. Non solo prevenire le malattie
ma preservare la salute
Mental heath
QoL
Mood
BADL
Emotional
Well being Physical health
Aegiosm Stigma
Qo
Socialization Physiscal function
Spiritual life
support…. Non solo prevenire le malattie
ma preservare la salute
Mental heath
QoL
Mood
BADL
Emotional
Well being Physical health
Aegiosm Stigma
Qo
Socialization Physiscal function
Spiritual life
support
“Healthy aging”Locomotion
Vitality Cognition
INTRINSIC
CAPACITY
Psychosocial Sensory
…concetto di salute/riserva funzionale e non malattia/perditaTake home messages • Increasing age and frequency of comorbidities are becoming the prevalent clinical picture of contemporary HIV disease • Total patient care allows to integrate the need for reaching un-detectability with the need to take care of comorbidities • • Polypharmacy increases the risk of DDIs and more studies are required to better understand the full impact of aging on the management of polypharmacy (Usefulness of TDM and DDI charts) • HIV Care implies a switch from a Inter-disciplinary approach into a Multi-dimensional comprehensive assessment INFC-1262103-0000-RTG-AV-06/2020
You can also read
