Heart Disease & Hepatotoxicity Among Leading Causes for Hospitalizations
Heart Disease, Renal, Hepatotoxicity, Anemia, non opportunistic infections are leading causes of hospitalizations for HIV-infected. They have overtaken opportunistic infections in terms of causes for hospitilations, but OI related causes are still occurring.
Selected Hospital Admission Rates for Patients Who Received HAART
Reported by Jules Levin
9th European AIDS Conference (EACS)
1st EACS Resistance & Pharmacology Workshop
October 26–29, 2003
C. Fichtenbaum1, D. Lee2, W. Broderick2, M. Emons2, G. Goldberg2, M. Haberman2, R. Vendiola2. University of Cincinnati, Cincinnati, Ohio, USA, 2Constella Health Strategies, Santa Monica, CA, USA. Funded by: Boehringer Ingelheim Pharmaceuticals, Inc.
The study objective is to evaluate the relative impact of key morbidities in the HIV population, analyzed data from several managed health care plans. Admission rates and discharge diagnoses were assessed to determine the relative frequency of adverse events for patients who were prescribed HAART.
The study examined 2000 and 2001 calendar year data contained within a large, managed care database. The managed care database contains private health care claims and enrollment data representing health care services provided through HMO, PPO, and specialty products to approximately three million medical members. Patient entry criteria included:
--Patient filled prescription drug claims for > 3 unique antiretroviral agents between Jan. 1, 2000 and June 30, 2000
--Patient > 18 years of age and < 90 years of age as of Dec. 31, 2000
--Patient was not covered by Medicare Supplemental Insurance
--Patient was eligible for medical benefits and pharmacy benefits throughout the study period
Hospital admission rates for conditions associated with HAART side effects and/or HIV infection were calculated for the Study Group. Discharge diagnoses and ICD-9-CM procedure information from each inpatient hospitalization claim were used to determine reasons for admission. Each admission was categorized into one or more of eight categories:
- Hepatitis/abdominal pain - Non-opportunistic infections - Opportunistic infections - Atherosclerotic cardiac and vascular disease - Kidney disease - Anemia/neutropenia/thrombocytopenia - Psychosis - Other
Patients in the study could have more than one diagnosis/procedure per admission. Patients who had admissions related to atherosclerotic cardiac and vascular disease were assigned to one or more comorbid condition categories. These categories were formed by grouping clinically similar ICD-9-CM diagnosis codes into one of 186 diagnostic groupings. The assignment was based on all facility and professional claims submitted during the study period. RESULTS
The demographic characteristics of the Study Group receiving HAART:
--756 in study (100%)
--Median age was 45 years
--81.5% were male
--71% had exposure to protease inhibitors (PIs)
DEMOGRAPHIC CHARACTERISTICS OF HOSPITALIZED vs NON-HOSPITALIZED PATIENTS in the Study Group Receiving HAART
--The hospitalized group represented 23% of the Study Group (29% of females and 22% of males)
--Median age for hospitalized patients was 46 years
--77% of hospitalized patients were male
174 of 756 patients were hospitalized: 34% were 35-44, 27% were 45-54, 9% were 25-34, 1% were 18-24, 16% were 55-64, and 12% were 65+ yrs old.
There were 340 hospital admissions during the study period. The admission rate for all selected reasons was 44.97 per 100.
--Admissions for atherosclerotic cardiac and vascular disease were the most commonly observed reason for admission after non-opportunistic infections
--The admission rate for atherosclerotic cardiac and vascular disease was approximately 50% higher than the admission rate for hepatitis/abdominal pain (p<0.05).
--The mean age of patients admitted for atherosclerotic cardiac and vascular disease was 55.6 years, and 80%were male.
--Among the patients admitted for atherosclerotic cardiac and vascular disease, 42.5% had a comorbid diagnosis of hypertension and 22.5% diabetes.
--The admission rate for opportunistic infections was ranked last among the conditions studied.
TOP REASONS FOR HOSPITAL ADMISSION
(admission rates per 100 patients)
Non opportunistic infections: 9.8% Cardio vascular disease: 8.5% Renal: 5.8% Hepatotoxicity: 5.6% (CV vs Hepatotoxicity, p<0.05) Anemia (include Neutropenia, thrombocytopenia): 5.0% Opportunistic infections: 3.4%
AUTHOR DISCUSSION and CONCLUSIONS
Through the introduction of new, effective drug treatments, the prognosis for patients with HIV/AIDS has improved dramatically over the past decade. HIV therapy has evolved from the treatment of life-threatening complications to the management of a chronic disease. Opportunistic infections are no longer a primary adverse event leading to hospital admission. Comorbid conditions and adverse drug events are now significant factors determining clinical outcomes for patients receiving HAART.
Clinicians managing HIV patients should pay increased attention to risk factors for cardiac, renal or hepatic disease.
--Cardiovascular-related adverse events were the leading cause of morbidity among conditions associated with known complications of antiretroviral therapy. (editorial note: but, studies suggest end stage liver disease is the leading cause of death in HIV)
--The association of HAART with dyslipidemia and hyperglycemia is well established.
--The increased risk of cardiovascular disease associated with exposure to HAART, primarily PIs, is likely mediated by the effects HAART has on the metabolism of lipids and glucose.
--In this study, the relatively high prevalence of hypertension and diabetes among those hospitalized with cardiovascular conditions is consistent with other reports that known cardiac risk factors contribute to the risk of cardiovascular comorbidity in the HIV population.
--Evidence continues to accumulate suggesting that HIV patients on HAART may have a higher incidence of acute coronary events.
--Patients at greatest risk of hepatoxicity are those with comorbid chronic hepatitis, which can be diagnosed with liver function tests and serology.
Conclusion Results from the present study demonstrate that HIV patients are more often hospitalized due to atherosclerotic cardiovascular disease than for conditions related to renal disease, hepatotoxicity or opportunistic infections. These results suggest that risk factors for cardiovascular disease should be an important consideration for physicians prescribing HAART regimens, particularly in treating patients over the age of 40. Therapeutic considerations should include smoking cessation, the management of lipids and hyperglycemia, and the careful selection of antiretroviral agents.