The DCRI’s Eric Peterson, MD, MHS, recently reviewed an important study in JAMA examining novel strategies to de-escalate hypertension treatment in older adults.
When caring for older adults with high blood pressure, individualized treatment plans are critical—and in some cases, reducing the number of medications may even be the most appropriate answer, writes DCRI’s Eric Peterson, MD, MPH, in a recent editorial in JAMA.
The editorial, which Peterson wrote in collaboration with Michael Rich, MD, of Washington University School of Medicine in St. Louis, analyzes the results of a pragmatic trial also published in JAMA. The trial, which was conducted in the U.K. by James Sheppard, PhD, and colleagues, examined the impacts of deprescribing, or reducing the dosage or number of medications a person is taking, on adults aged 80 and older.
When blood pressure was measured at the end of the 12-week study, the study team found no significant difference between the group that had their medications reduced and the group that received usual care. These findings indicate that deprescribing can be a viable strategy for treating older adults with hypertension, which is important because taking multiple medications, or polypharmacy, can have many negative impacts for these patients, including lower adherence rates or higher likelihood of negative interactions between medications.
Although the editorial authors commend the study team for evaluating an important patient-centric issue using a pragmatic trial design, they also point to limitations of the study. These include:
- Long-term safety of this deprescribing strategy has not been proven, and larger studies with longer follow-up are needed and underway.
- There were numerically higher numbers of adverse events in the deprescribing group. Although the difference was not statistically significant, one-third of patients in the deprescribing group had to have their medications restarted by the study’s end.
- The blood pressure target set as the primary endpoint was lenient. If one examined the outcomes using current U.S. guideline standards, the deprescribing method was found to be inferior to usual care of leaving patients on all of their medications.
- The trial was unblinded, leaving more room for bias—for example, unlike patients in the usual care group, patients in the deprescribing group were encouraged to self-monitor their blood pressure, which may have contributed to improved medication adherence.
Despite these limitations, Peterson and his co-author conclude, the study supports the potential for deprescribing as an important strategy to consider in the treatment of hypertension in older adults. The study also serves as a reminder that clinicians should evaluate each medication in a patient’s regimen in order to determine whether the benefits of taking it outweigh the risks, while working with their patients to make individualized treatment decisions.
The study and the editorial were also covered in Cardiology Today.