Antiretroviral Treatment and Age-related Comorbidities in Older HIV Patient
Antiretroviral Treatment and Age-related Comorbidities in Older HIV Patient
Background: The availability of several therapeutic regimens has transformed HIV infection from a life-threatening disease into a chronic condition. Older patients (>50 years old) with HIV infection constitute a new treatment challenge in terms of the cumulative effects of ageing and antiretroviral therapy (ART).
Methods: The immunovirological effects and metabolic interactions of 48 weeks of ART in older patients followed up in three Infectious Diseases Units in Milan, Italy since 1994 were compared with those in younger controls aged 25-35 years.
Results: The 159 older patients and 118 controls enrolled in the study were comparable for HIV stage, baseline CD4 cell count and viral load but differed for mode of HIV transmission, comorbid conditions and related chronic treatments. Mean viral load decreased after 48 weeks of treatment by 2.6 log10 HIV RNA copies/mL and CD4 count increased by 137.5 cells/μL in older patients, and similar values for immunovirological effects were obtained in the young controls. The relative risk (RR) of an abnormal test in older patients was 7.33 [95% confidence interval (CI) 4.36-12.36] for glucose, 1.73 (95% CI 1.45-2.07) for total cholesterol, 1.56 (95% CI 1.22-2.0) for high-density lipoprotein cholesterol, 1.26 (95% CI 1.02-1.56) for triglycerides, 6.48 (95% CI 4.36-9.66) for serum creatinine, and 0.45 (95% CI 0.35-0.58) for ALT. Moderate/severe liver and renal toxicities were recorded in the older patients but not in the controls. The tolerability of ART did not differ between the older patients and the controls. Thirty-nine new cardiovascular, endocrine-metabolic and neuralgic disorders (24.52 per 100 person-years) were diagnosed in the older patients and four (3.39 per 100 person-years) in the controls (P<0.0001).
Conclusions: Diseases induced by, or related to, the toxic effects of antiretrovirals interact with age-specific health profiles, raising new questions and challenges. Comparative epidemiological studies, research studies addressing specific questions and surveillance are needed to answer the questions that arise in clinical monitoring.
In recent years, the clinical history of HIV infection has been modified by three main factors: (i) the widespread use of highly active antiretroviral therapy (HAART), which has reduced mortality; (ii) new therapeutic strategies, which have transformed HIV infection from a life-threatening disease into a chronic condition, and (iii) the identification of risk factors for side effects and untoward effects of each antiretroviral drug, which has allowed treatment to be tailored to each patient.
As a consequence, a new variable must be considered by healthcare professionals: the ageing of HIV-infected people. HIV-infected adults older than 50 years represent more than 10% of the HIV-infected population and 15% of all people living with AIDS. These percentages are expected to increase with time. Individuals with HIV/AIDS are living longer following the introduction of HAART, and the mean age of HIV-infected people has increased since the beginning of the epidemic in industrialized countries.
Among patients with AIDS in Italy, the median age has increased from 29 years for male patients and 24 years for female patients in 1985 to 41 and 38 years, respectively, in 2004. The overall rate of AIDS diagnosis among patients older than 50 years has increased from 5.3% to 10.2% in 10 years (1990-2001).
More than 50% of patients on HAART are expected to live beyond their 60s. Reliable epidemiological estimates are lacking for elderly patients, and little is known about the interactions between ageing and HIV infection, both in the field of disease progression and in the field of antiretroviral treatment effectiveness, tolerability and short- and long-term toxicity, the pharmacokinetics of antiretroviral drugs, and interactions between HAART and underlying diseases and their treatments.
Older age has been associated with faster progression of HIV infection and shorter survival time after the diagnosis of AIDS. Randomized, controlled clinical trials for the evaluation of antiretroviral drugs or therapeutic strategies generally exclude older patients and/or those with concurrent disorders. No recommendations about the most appropriate timing and type of antiretroviral treatment are given in the international guidelines for the use of antiretroviral agents in older HIV-1-infected patients. Scientific data, based on case reports or limited studies, do not help healthcare professionals to properly treat older HIV-infected individuals.
Physiological changes observed with ageing, including increased risk of infection, reduced immunocompetence, the appearance of several comorbid conditions which can affect the disease process and complicate its management, and interactions among antiretrovirals and drugs used for the treatment of other diseases, underline the need for age-related evaluations of treatment and management strategies.
In this study, we evaluated immunovirological outcomes and the incidence rate of adverse metabolic events or new comorbidities in the first year of antiretroviral treatment in an HIV-infected cohort of patients aged 50 years or older, followed up in three Infectious Diseases Units of the L Sacco Hospital, Milan, Italy.
Abstract and Introduction
Abstract
Background: The availability of several therapeutic regimens has transformed HIV infection from a life-threatening disease into a chronic condition. Older patients (>50 years old) with HIV infection constitute a new treatment challenge in terms of the cumulative effects of ageing and antiretroviral therapy (ART).
Methods: The immunovirological effects and metabolic interactions of 48 weeks of ART in older patients followed up in three Infectious Diseases Units in Milan, Italy since 1994 were compared with those in younger controls aged 25-35 years.
Results: The 159 older patients and 118 controls enrolled in the study were comparable for HIV stage, baseline CD4 cell count and viral load but differed for mode of HIV transmission, comorbid conditions and related chronic treatments. Mean viral load decreased after 48 weeks of treatment by 2.6 log10 HIV RNA copies/mL and CD4 count increased by 137.5 cells/μL in older patients, and similar values for immunovirological effects were obtained in the young controls. The relative risk (RR) of an abnormal test in older patients was 7.33 [95% confidence interval (CI) 4.36-12.36] for glucose, 1.73 (95% CI 1.45-2.07) for total cholesterol, 1.56 (95% CI 1.22-2.0) for high-density lipoprotein cholesterol, 1.26 (95% CI 1.02-1.56) for triglycerides, 6.48 (95% CI 4.36-9.66) for serum creatinine, and 0.45 (95% CI 0.35-0.58) for ALT. Moderate/severe liver and renal toxicities were recorded in the older patients but not in the controls. The tolerability of ART did not differ between the older patients and the controls. Thirty-nine new cardiovascular, endocrine-metabolic and neuralgic disorders (24.52 per 100 person-years) were diagnosed in the older patients and four (3.39 per 100 person-years) in the controls (P<0.0001).
Conclusions: Diseases induced by, or related to, the toxic effects of antiretrovirals interact with age-specific health profiles, raising new questions and challenges. Comparative epidemiological studies, research studies addressing specific questions and surveillance are needed to answer the questions that arise in clinical monitoring.
Introduction
In recent years, the clinical history of HIV infection has been modified by three main factors: (i) the widespread use of highly active antiretroviral therapy (HAART), which has reduced mortality; (ii) new therapeutic strategies, which have transformed HIV infection from a life-threatening disease into a chronic condition, and (iii) the identification of risk factors for side effects and untoward effects of each antiretroviral drug, which has allowed treatment to be tailored to each patient.
As a consequence, a new variable must be considered by healthcare professionals: the ageing of HIV-infected people. HIV-infected adults older than 50 years represent more than 10% of the HIV-infected population and 15% of all people living with AIDS. These percentages are expected to increase with time. Individuals with HIV/AIDS are living longer following the introduction of HAART, and the mean age of HIV-infected people has increased since the beginning of the epidemic in industrialized countries.
Among patients with AIDS in Italy, the median age has increased from 29 years for male patients and 24 years for female patients in 1985 to 41 and 38 years, respectively, in 2004. The overall rate of AIDS diagnosis among patients older than 50 years has increased from 5.3% to 10.2% in 10 years (1990-2001).
More than 50% of patients on HAART are expected to live beyond their 60s. Reliable epidemiological estimates are lacking for elderly patients, and little is known about the interactions between ageing and HIV infection, both in the field of disease progression and in the field of antiretroviral treatment effectiveness, tolerability and short- and long-term toxicity, the pharmacokinetics of antiretroviral drugs, and interactions between HAART and underlying diseases and their treatments.
Older age has been associated with faster progression of HIV infection and shorter survival time after the diagnosis of AIDS. Randomized, controlled clinical trials for the evaluation of antiretroviral drugs or therapeutic strategies generally exclude older patients and/or those with concurrent disorders. No recommendations about the most appropriate timing and type of antiretroviral treatment are given in the international guidelines for the use of antiretroviral agents in older HIV-1-infected patients. Scientific data, based on case reports or limited studies, do not help healthcare professionals to properly treat older HIV-infected individuals.
Physiological changes observed with ageing, including increased risk of infection, reduced immunocompetence, the appearance of several comorbid conditions which can affect the disease process and complicate its management, and interactions among antiretrovirals and drugs used for the treatment of other diseases, underline the need for age-related evaluations of treatment and management strategies.
In this study, we evaluated immunovirological outcomes and the incidence rate of adverse metabolic events or new comorbidities in the first year of antiretroviral treatment in an HIV-infected cohort of patients aged 50 years or older, followed up in three Infectious Diseases Units of the L Sacco Hospital, Milan, Italy.
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