HIV: A clinical opportunity for community pharmacy

Opportunities arise daily for community pharmacists to function as clinically as their hospital-based counterparts. Many pharmacies have begun to offer free blood pressure or blood sugar testing; some are even performing health screenings such as lipid panels and HIV screenings. Pharmacists are becoming leaders in diabetes or hypertension management and are proficient in discussing these subjects with their patients.

The services gap

As services for some disease states have flourished, those for other treatment areas such as oncology, mental health, and HIV/AIDS seem to have fallen by the wayside. The novel pharmacotherapy of these “complex” medical conditions may intimidate pharmacists. In practice, a pharmacist may receive prescriptions and simply accept them as correct, without being certain that the medications prescribed by the doctor are appropriate. In the case of HIV, many pharmacists may be confused by the extensive array of medications, the complex regimens, the question of whether a regimen is correct, or even the best way to counsel a patient in the use of these medications.

At present there are 25 approved medications for the treatment of HIV/AIDS (not including the combination drugs such as Truvada or Stribild). These medications together make up six drug classes: nucleoside reverse transcriptase inhibitors (NRTIs), non-nucleoside reverse transcriptase inhibitors (nNRTIs), protease inhibitors (PIs), fusion inhibitors, CCR5 inhibitors, and the new class of integrase inhibitors.

Remember, though, that in hypertension pharmacotherapy there are at least 12 classes of medications, including loop diuretics, thiazide diuretics, ACE inhibitors, ARBs, beta-blockers, two types of calcium channel blockers, etc. There are twice as many classes of antihypertensive drugs as there are classes to treat HIV/AIDS. And yet you learned everything you needed to know about every drug included in each class of hypertension agents.

Adding to the confusion connected with HIV medications is the fact that there are three names for each agent (trade name, generic name, and abbreviation). While this can seem daunting, it can be overcome, just as we have learned the brand and generic names for all the other medications and can recall them without much struggle.        

Know your stuff

Another issue that arises in the management of HIV medications is that many pharmacists may not fully understand what constitutes an appropriate therapy regimen. There are many resources available online that offer quick and easy information to help determine the appropriateness of a regimen. For a credible resource on all available medications, a thorough pocket guide can be found under the Resources page at www.fcaetc.org.

Consider hypertension, for example. How many patients’ conditions are currently controlled only by HCTZ or lisinopril? Or take the case of patients living with diabetes. How many of them are simply receiving metformin? The point is that all disease states have difficult, complex regimens. Pharmacists must take the time to learn the basics in every instance

 Knowledge is the pharmacist’s first step toward becoming an active leader in the management of HIV medications. As the medication expert of the healthcare team, the pharmacist should be able to determine which medications go in which classes. Once this is achieved, it is much simpler to determine whether a regimen is appropriate or not.

The proverbial monkey wrench comes in when resistance develops and the traditional regimen is altered. For example, some patients may be on one NRTI, one nNRTI, and one PI - or they could be on two NRTIs only. Still other patients may be on salvage therapy and receiving two NRTIs, one nNRTI, one PI, and an integrase inhibitor. When these unusual regimens appear, the best practice is to call the doctor and confirm that the regimen is correct.

Which is worse: taking a few minutes to call the doctor and get the patient on the correct medications to help control his or her disease, or just assuming that it is correct and letting the patient walk out the door with an inappropriate regimen?

Counseling

Another way that the community pharmacist can make a significant impact in connection with HIV is through knowledge of basic counseling points that come with these medications. Reminding patients to take their efavirenz (Sustiva) at night or avoiding PPIs with atazanavir (Reyataz) can go a very long way.

When pharmacists counsel patients on these medications, it is very important to continue to give them positive reinforcement. One of the most important issues to discuss with patients in connection with HIV medications is compliance. Stressing that patients remain compliant is a simple thing, but it can have a critical effect on a patient’s prognosis.

Consider offering feedback to physicians on patients who may not be taking their medications appropriately. Be sure to take action to determine reasons for nonadherence.

As the healthcare system continues to evolve, pharmacists have many opportunities to interact with patients and make a positive impact on their health, and they can play an active role in the treatment of patients with HIV. So the next time you refill the prescription for Truvada, take a second and think, “Is this the correct medication? Where is the rest of the drug regimen?” It could save a life.

Ben Culpepper is the PGY-2 Community Pharmacy Resident with the University of North Carolina School of Pharmacy and Kerr Drug in Chapel Hill, N.C. Contact him at ben.culpepper@gmail.com. David Pope is the chief of innovation and co-founder of http://CreativePharmacist.com/. Contact him at david@CreativePharmacist.com.