Risk factors

Can deprescribing antihypertensives be done safely in the elderly?

Deprescribing antihypertensive medications in patients 80 years and over is feasible and noninferior to usual care after 12 weeks follow-up, a UK study shows.

Oxford University ressearchers randomised 569 elderly patients with systolic BP <150 mm Hg and receiving at least two antihypertensive medications to removal of one medication or usual care in which there were no medication changes.

The unblinded study, published in JAMA, found 86.4% of patients in the intervention group and 87.7% in the control group maintained their systolic BP below 150 mm Hg at 12 weeks.

The mean change in systolic BP was 3.4mm Hg higher in the medication reduction group compared with usual care after correcting for baseline blood pressure.

“When analyses were restricted to those patients who maintained medication reduction throughout follow-up (per-protocol population), a greater increase in systolic and diastolic blood pressure was seen in the intervention group,” the study said.

The Optimising Treatment for Mild Systolic Hypertension in the Elderly (OPTIMISE) trial found the medication reduction was maintained in 66.3% of the intervention group.

Participants in the medication reduction group were taking 0.6 fewer antihypertensive medications than the usual care group at 12-week follow-up

Secondary outcomes such as quality of life and frailty were not significantly different between the two groups.

The number of patients experiencing at least 1 adverse event was significantly higher in the medication reduction group (12 v 7; adjusted RR 1.28).

However an accompanying editorial highlighted the fact that the long-term outcomes of medication reduction was unknown.

“At end of the trial, the systolic BP in the deprescribing group was, on average, 3.4 mm Hg (95% CI, 1.1 to 5.8) higher, relative to the control group.”

“Although this absolute difference may seem minimal, such differences in BP can potentially lead to long-term differences in outcomes at the population level.”

And it said the primary endpoint of systolic BP <150 mmHg was a relatively low bar.

“Even though this 150 mm Hg treatment threshold is consistent with UK guidelines, the US guidelines call for a more stringent systolic BP target of 130 mm Hg. Had this been the outcome of the study, the deprescribing strategy would have failed to be considered noninferior to usual care (adjusted RR, 0.76 [97.5% CI, 0.63 to ∞]; P = .98).”

It said larger studies with longer follow-up are needed before widespread adoption of deprescribing antihypertensive therapy in older adults.

“In the meantime, clinicians should con-sider the fundamental concept inherent to deprescribing: that medications should continuously be reviewed to assure that their potential benefits outweigh potential risks. This is part of good prescribing practice in care of older adults.”

“But such decisions will need to be individualized for each patient and take into account current health state and personal health values and goals. In some cases, when treating an older patient with high BP, more medications (to achieve lower targets) may be beneficial; while in others, less medications (when safe) will truly be more.”

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