Pulling Back BP Meds Feasible in the Elderly

Deprescribing antihypertensive medications was feasible and noninferior to usual care for geriatric patients, in whom the benefits of lower blood pressure (BP) and multiple antihypertensive prescriptions may not outweigh the risks, the OPTIMISE randomized trial found.

People age 80 years and older had similar rates of systolic BP <150 mm Hg at 12 weeks whether they were assigned to have one BP-lowering drug removed or to continue usual care (86.4% vs 87.7%, adjusted RR 0.98). The 95% confidence interval’s lower bound of 0.92 met the prespecified noninferiority margin.

However, BP did rise significantly by 3.4/2.2 mm Hg with deprescribing compared with controls, investigators led by James Sheppard, PhD, of the University of Oxford, England, reported in JAMA.

“What this trial has shown is that withdrawal of a BP agent is associated with a small rise in BP in patients older than 80 years with multimorbidity, mild frailty, polypharmacy, or a combination of these characteristics,” Sheppard’s group said of their 569-person study.

Although the small rise in BP might suggest caution when adopting this approach in routine clinical practice, it’s “unclear whether an increased risk of cardiovascular disease is as important in an older population in which there are competing risks from other conditions,” they said.

“While the study demonstrated that deprescribing was achievable for antihypertensive therapy, it did not prove that the strategy was safe,” warned Eric Peterson, MD, MPH, of Duke University Medical Center in Durham, North Carolina, and Michael Rich, MD, of Washington University School of Medicine in St. Louis, in an accompanying editorial.

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

BP targets for people over 80 are 150 mm Hg according to the U.K. and the American College of Physicians/American Academy of Family Physicians, but 130 mm Hg under American Heart Association/American College of Cardiology guidelines.

The lower target was largely based on SPRINT, which was not representative of frail patients with multimorbidity, Sheppard’s team noted.

In addition to their main findings, the group reported no significant advantage to deprescribing in terms of frailty, quality of life, or reduced adverse events. It may be that these supposed benefits require longer-term follow-up and greater statistical power to be detected, they said.

However, serious adverse events (such as falls and GI hemorrhage) were numerically elevated in the medication reduction group (4.3% vs 2.4%, adjusted RR 1.72, 95% CI 0.7-4.3), Peterson and Rich pointed out.

OPTIMISE was an unblinded trial of older people with systolic BP lower than 150 mm Hg on at least two BP-lowering medications who were considered eligible for medication reduction by their primary care doctors in England. Excluded were people with heart failure or recent MI or stroke.

The resulting cohort averaged 84.8 years old, with 48.5% women. Mean systolic BP at baseline was 129.4 mm Hg in the medication reduction group and 130.5 mm Hg in the usual care group.

Two-thirds of those in the deprescribing group were able to stay off the withdrawn BP drug at 12 weeks. Overall, this group as a whole averaged 0.6 fewer antihypertensives at follow-up compared with controls.

Sheppard and colleagues acknowledged that the OPTIMISE population was highly selected and that the investigators did not measure adherence to medications in either group.

The unblinded design of the trial also meant that BP measurements and event reporting could have been biased.

“On the patient side, the participants in the medication reduction group were encouraged to self-monitor their BP, a practice that generally leads to better medication adherence and better BP control, whereas the usual care group was not encouraged to self-monitor BP,” Peterson and Rich noted. “Dose titration was allowed and may have been more common in the medication-reduction group.”

“Despite its limitations, the study by Sheppard et al provides important data supporting the proof of concept of deprescribing in older adults,” they maintained.

The good news is that longer-term deprescribing trials are ongoing, according to the editorialists.

“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,” Peterson and Rich emphasized.