BP control in older patients feasible with medication reduction
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Medication reduction in older patients treated with multiple antihypertensive medications was noninferior to usual care regarding the control of systolic BP at 12 weeks, according to data from the OPTIMISE trial published in JAMA.
“For those doctors and patients who have decided that reducing medication is appropriate for them, this trial provides a structured approach for antihypertensive deprescribing,” James P. Sheppard, PhD, university research lecturer at the Nuffield department of primary care health sciences at University of Oxford, told Healio. “However, due to the short-term follow-up in the trial, we do not yet know the long-term clinical implications of such an approach.”
Older patients taking multiple medications
Researchers analyzed data from 569 patients (mean age, 85 years; 49% women) from England aged 80 years and older with a systolic BP lower than 150 mm Hg who were prescribed two or more antihypertensive medications for at least 12 months. Physicians enrolled these patients if they thought they may potentially benefit from a medication reduction. Patients were assigned an antihypertensive medication reduction strategy (n = 282; mean age, 85 years; 47% women) or usual care (n = 287; mean age, 85 years; 51% women), both of which were administered for 12 weeks.
Physicians of patients in the intervention group used a medication reduction algorithm to determine which antihypertensive drug to remove. A safety monitoring algorithm was then used during follow-up. The removed antihypertensive medication could be reinstated if systolic BP was above 150 mm Hg, diastolic BP was above 90 mm Hg for more than 1 week, signs of accelerated hypertension developed or if adverse events occurred.
“It is worth remembering that the medication reduction trialed in this study was implemented and carefully monitored by trained doctors,” Sheppard said in an interview. “We would not recommend any patients stopping their prescribed medications without consulting and agreeing with their doctor first.”
Patients assigned usual care continued to take all of their antihypertensive medications with no changes to their medications.
Both groups were followed up periodically for 12 weeks. The primary outcome was the RR for the control of systolic BP between groups at 12 weeks. Secondary outcomes were also assessed, including the proportion of patients assigned the intervention who maintained medical reduction, in addition to between-group differences in quality of life, frailty, adverse events, serious adverse events and change in systolic and diastolic BP during the 12-week follow-up.
Of the patients in the trial, 93.8% completed follow-up. At 12 weeks, systolic BP less than 150 mm Hg was observed in 86.4% of patients assigned the intervention and 87.7% of those assigned usual care (adjusted RR = 0.98; 97.5% 1-sided CI, 0.92-).
Five of the seven prespecified secondary endpoints showed no significant differences. Medication reduction continued to 12 weeks in 66.3% of patients. Compared with the control group, the intervention group had a 3.4 mm Hg higher mean change in systolic BP (95% CI, 1.1-5.8). At least one serious adverse event occurred in 4.3% of patients assigned the intervention and 2.4% of those assigned usual care (aRR = 1.72; 95% CI, 0.7-4.3).
“Although there are differences in the way health care is provided in England and the U.S., medications used to treat hypertension are the same, and until recently, guidelines on when to prescribe them were similar,” Sheppard told Healio. “Indeed, since many clinical guidelines in the U.S. now recommend more intensive treatment targets for hypertension, it is likely that more and more patients who experience issues with polypharmacy, and so deprescribing strategies such as the one we trialed will become more relevant.”
Further research
Sheppard added that more research is needed in this area. He said, “The key question that remains is what are the long-term impacts of deprescribing on hospital admission, cardiovascular disease and death, as well as quality of life, cognitive function and physical disability. Until we know this, it remains unclear whether or not medication reduction should be encouraged in routine clinical practice.”
In a related editorial, Eric D. Peterson, MD, MPH, professor of medicine, Fred Cobb, MD Distinguished Professor of Medicine, core faculty member at Duke-Margolis Center for Health Policy and member in the Duke Clinical Research Institute at Duke University School of Medicine, and Michael W. Rich, MD, director of the cardiology fellowship clinical research training program and of the cardiac rapid evaluation unit at Barnes-Jewish Hospital and professor of medicine at Washington University School of Medicine in St. Louis, wrote: “In the meantime, clinicians should consider 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.” – by Darlene Dobkowski
References:
Peterson ED, et al. JAMA. 2020;doi:10.1001/jama.2020.4871.
For more information:
James P. Sheppard, PhD, can be reached at james.sheppard@phc.ox.ac.uk; Twitter: @jamessheppard48.
Perspective
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Parag Goyal, MD, MSc, FACC
Polypharmacy, or the condition of taking a high number of medications, is increasingly common with advancing age and is linked with adverse outcomes. Deprescribing has emerged as a potential strategy to address polypharmacy and potentially mitigate its adverse effects.
This study sought to examine the impact of deprescribing (specifically a reduction in antihypertensive agents) among older adults aged at least 80 years with hypertension. Conducting this study was important because it has provided unique insights on whether deprescribing antihypertensive medications is safe at least in the short term.
The key result was that deprescribing antihypertensive agents did not lead to an increased proportion of patients with an unacceptable BP (systolic BP above 150 mm Hg) compared to usual care (continuation of antihypertensive agents) at 12 weeks. In the deprescribing group, systolic BP increased by 3.4 points. Although 3.4 points of BP may translate to an increased risk of adverse outcomes on a population level, such small changes in an individual patient may not lead to an increase in adverse events; just as importantly, if a reduction in medications improves other aspects of life (reduced pill burden, reduced side effects), the three to four points in BP may be worth it to the individual patient.
It is worth noting that there was a signal of possible harm in the deprescribing group, but the CIs were very wide and the adverse outcomes measured don’t all have a biologically plausible link to an elevation of 3.4 points in systolic BP, so it’s challenging to interpret the meaning of that finding at this time.
Although these findings do not provide any definitive results at this time, they suggest that deprescribing antihypertensive agents in some older adults may be reasonable. Discussion related to deprescribing should incorporate baseline risk (including baseline BP), an assessment of whether a particular antihypertensive agent is potentially contributing to untoward effects and an understanding of an individual patient’s health goals.
There is a major need to develop strategies for addressing polypharmacy, and more broadly, for improving medication prescribing practice. Deprescribing is a very promising strategy for improving outcomes but is vastly underutilized for a host of reasons. It is still not clear which medications to target, in which clinical contexts and among which patients.
It is also unclear how best to implement deprescribing in a safe and effective way. Hopefully, this important work will advance the field and spur additional study into deprescribing.
With the recent development of the U.S. Deprescribing Research Network, I am optimistic that this field will advance very quickly and further enhance safe and patient-centric medication prescribing practice.
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