Is it safe to deprescribe antihypertensives in older adults?

Deprescribing—the supervised process of intentionally reducing or stopping medication—has emerged as a strategy to reduce medication overuse and mitigate risks associated with taking multiple medications. The effect of deprescribing antihypertensive medications on cardiovascular outcomes in long-term care residents, however, is unclear. To examine this issue, researchers compared the incidence of hospitalization for myocardial infarction (MI) or stroke among long-term care residents who were deprescribed or continued on antihypertensive therapy.1The observational study used electronic health record data from long-term care residents (age ≥ 65 years) who were taking at least one antihypertensive medication and admitted to U.S. Department of Veterans Affairs community living centers from 2006–2019. The population had a high burden of chronic conditions, most commonly diabetes (49.8%), coronary heart disease (39.8%), cerebrovascular disease (43.3%) and depression (52.6%). Antihypertensive medications included orally administered β-blockers, calcium channel blockers, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, central α-blockers, vasodilators, and loop, thiazide and potassium-sparing diuretics.1A deprescribing event was defined as a reduction in the number of antihypertensive medications or a reduction in dose of 30% or more compared with the previous week and sustained for at least two weeks. The main outcome was hospitalization with MI or ischemic or hemorrhagic stroke that included an emergency department visit.1 Results showed the following:The study included 13,096 long-term care residents (97.4% men; median age 77 years) taking at least one antihypertensive medication.Of these, 17.8% were deprescribed antihypertensive medication over a period of 12 weeks.At the time of deprescribing, median systolic and diastolic blood pressure values were 127 mmHg and 69 mmHg, respectively, in the deprescribed group and 129 mmHg and 70 mmHg, respectively, in the not deprescribed group.The estimated unadjusted cumulative incidence of stroke or MI hospitalization over two years was similar among residents who were and were not deprescribed antihypertensives (11.2% vs 8.8%; difference, 2.4 percentage points [95%CI, −2.3 to 7.1 percentage points]). After full adjustment for confounding, results showed no association of antihypertensive deprescribing with MI or stroke hospitalization (hazard ratio, 0.93; 95%CI, 0.70–1.26).1The investigators conclude that in this study of predominantly male long-term care residents, deprescribing antihypertensive medication was not associated with increased risk of hospitalization for MI or stroke. These findings may be useful for long-term care residents and clinicians who are considering deprescribing antihypertensive medications.1 The authors recognize that treatment decision-making requires a holistic evaluation of benefits and harms, and this study examined only cardiovascular disease hospitalizations. They advocate for more research on deprescribing methods and their potential consequences to help inform shared decision-making among patients and clinicians. Future research should also include more diverse populations and determine whether the effects of deprescribing differ by other meaningful characteristics.1The author of an accompanying commentary points out that much of the prior literature has focused on deprescribing potentially harmful or high-risk medications for which harms outweigh benefits, such as cognition-affecting medications (e.g., benzodiazepines), strongly anticholinergic medications, or those that increase the risk of falls. Far fewer studies have examined the impact of deprescribing medications that may be borderline beneficial or potentially unnecessary, such as the antihypertensives studied in this trial. Overall, the commentary highlights that results of this study contribute to our knowledge about the risks and benefits of deprescribing in older adults, beyond just high-risk medications.2References:Odden MC, Graham LA, Liu X, et al. Antihypertensive deprescribing and cardiovascular events among long-term care residents. JAMA Netw Open 2024;7(11):e2446851. (accessed November 28, 2024).Lauffenburger JC. Moving deprescribing beyond potentially harmful medications. JAMA Netw Open 2024;7(11):e2446857. (accessed November 28, 2024).

Is it safe to deprescribe antihypertensives in older adults?

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