Is it safe to reduce blood pressure medications for older adults? – Harvard Health Blog

“Doctor, can you take any of my medications?” I take too many pills. “

As physicians, we frequently hear this request. The elderly are the population most affected by the issue of prescribing several drugs, called polypharmacy. Trying to organize long lists of medications and remembering to take them exactly as prescribed can become a full-time job. In addition to the physical and emotional burden of organizing medications, older people are at increased risk for certain types of side effects and potentially worse outcomes from polypharmacy.

High blood pressure is a common source of prescriptions, as older people often find themselves on multiple medications to lower their blood pressure. Data from the Framingham Heart Study shows that over 90% of middle-aged people will eventually develop high blood pressure, and at least 60% will continue to take blood pressure lowering drugs.

The OPTIMIZE trial, recently published in JAMA, investigated the effect of reducing the number of blood pressure medications, also called deprescribing, in the elderly.

What Should Be Low Blood Pressure In The Elderly?

Previous large studies, including the HYVET trial and the more recent SPRINT trial, have shown that treating high blood pressure in the elderly remains important and may reduce the risk of heart attack, heart failure. , stroke and cardiovascular death. Black adults represented 31% of the SPRINT study population; therefore, study results could be used to make recommendations for this population, which is at increased risk for high blood pressure. However, many groups of older people were excluded, including residents of nursing homes, people with dementia, diabetes, and other conditions common to more frail older people.

The most recent guidelines from the American College of Cardiology (ACC) and the American Heart Association (AHA), published in 2017, define optimal blood pressure as being below 120/80 for most people, including people aged 65 and over. They recommend a goal of 130/80 for blood pressure treated with medication. The 2018 guidelines from the European Society of Cardiology (ESC) and the European Society of Hypertension (ESH) recommend a more relaxed goal of less than 140/90.

The US and European populations differ in their risk for cardiovascular disease, with the US population generally considered to be at higher risk for stroke, heart failure, and heart attack, so it might be appropriate to have goals of different blood pressure for these two groups. Either way, both groups recognize that factors such as frailty, limited life expectancy, dementia, and other medical issues need to be considered when developing personalized goals for women. patients.

What happened to older patients whose blood pressure medications were reduced?

The OPTIMIZE trial provided preliminary evidence that some older people may be able to reduce the number of blood pressure medications they take without causing a significant increase in blood pressure. For the trial, researchers randomized 569 patients aged 80 or older, with systolic blood pressure less than 150 mm Hg, either to stay on their current blood pressure medications or to withdraw at least one blood pressure medication. blood pressure according to a predefined protocol. Study subjects were followed for 12 weeks to assess blood pressure response.

The researchers found that people who continued to take their previous blood pressure medications and those who reduced the number of medications had similar blood pressure control at the end of the study. While the mean increase in systolic blood pressure for the drug-reducing group was 3.4 mm Hg greater than that of the control group, the number of patients with systolic blood pressure below the target of 150 mm Hg at the end of the study was not significantly different. between groups. About two-thirds of the patients may have been without medication by the end of the study.

It is important to note that OPTIMIZE is a relatively small study and that the researchers did not look at long-term outcomes such as heart attack, heart failure, or stroke for this study (as the HYVET trials did. and SPRINT), so we don’t. t know what the long-term effect of deprescribing would be.

More research is needed to examine the long-term effects of deprescribing

While the OPTIMIZE trial showed promise, larger, longer-lasting trials looking at results beyond blood pressure alone are needed to really know whether deprescribing is safe in the long term. Additionally, these researchers used a target systolic blood pressure below 150 mm Hg, which is above the most recent ACC / AHA and ESC / ESH recommendations.

An interesting aspect of the design of this study is that the primary care physician had to feel that the patient would be a good candidate for deprescribing. This left the possibility for physicians, who may know the patients well, to individualize their decisions regarding deprescribing.

The bottom line

This trial provides some support to physicians and other prescribers when considering a trial of deprescribing a blood pressure medication in some elderly patients, with the goal of improving quality of life. These patients should be followed closely to monitor their responses.

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Jothi Venkat

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