BackgroundGPs are confronted with therapeutic dilemmas in treating patients with multimorbidity and/or polypharmacy when unfavourable medication risk–benefit ratios (RBRs) conflict with patients’ demands.AimTo understand GPs’ attitudes about prescribing and/or deprescribing medicines for patients with multimorbidity and/or polypharmacy, and factors associated with their decisions.Design and settingCross-sectional survey in 2016 among a national panel of 1266 randomly selected GPs in private practice in France.MethodGPs’ opinions and attitudes were explored using a standardised questionnaire including a case vignette about a female treated for multiple somatic diseases, sleeping disorders, and chronic pain. Participants were randomly assigned one of eight versions of this case vignette, varying by patient age, socioprofessional status, and stroke history. Backward selection was used to identify factors associated with GPs’ decisions about drugs they considered inappropriate.ResultsNearly all (91.4%) responders felt comfortable or fairly comfortable deprescribing inappropriate medications, but only 34.7% decided to do so often or very often. In the clinical vignette, most GPs chose to discontinue symptomatic medications (for example, benzodiazepine, paracetamol/tramadol) because of unfavourable RBRs. When patients asked for ketoprofen for persistent sciatica, 94.1% considered this prescription risky, but 25.6% would prescribe it. They were less likely to prescribe it to older patients (adjusted odds ratio [AOR] 0.48, 95% confidence interval [CI] = 0.36 to 0.63), or those with a stroke history (AOR 0.55, 95% CI = 0.42 to 0.72).ConclusionIn therapeutic dilemmas, some GPs choose to prioritise patients’ requests over iatrogenic risks. GPs need pragmatic implementation tools for handling therapeutic dilemmas, and to improve their skills in medication management and patient engagement in such situations.

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This article sought to study the association between patterns of benzodiazepine (BZD) use and the risk of hip and forearm fractures in people aged 50 and 75 years or more. Methods: In a representative cohort of the French National Health Insurance Fund of individuals aged 50 years or older (n = 106 437), we followed up BZD dispensing (reflecting their patterns of use) and the most frequent fall-related fractures (hip and forearm) for 8 years. We used joint latent class models to simultaneously identify BZD dispensing trajectories and the risk of fractures in the entire cohort and in those 75 years or older). We used a survival model to estimate the adjusted hazard ratios (aHRs) between these trajectories and the risk of fractures. Results: In the entire cohort, we identified 5 BZD trajectories: non-users (76.7% of the cohort); occasional users (15.2%); decreasing users (2.6%); late increasing users (3.0%); and early increasing users (2.4%). Compared with non-users, fracture risk was not increased in either occasional users (aHR = 0.99, 95% confidence interval [CI] 0.99-1.00) or in decreasing users (aHR = 0.90, 95% CI 0.74-1.08). It was significantly higher in early increasing users (aHR = 1.86, 95% CI 1.62-2.14) and in late increasing users (aHR = 1.39, 95% CI 1.15-1.60). We observed similar trajectories and risk levels in the people older than 75 years. Conclusion: Occasional BZD use, which is compatible with current recommendations, was not associated with an excess risk of the most frequent fall-related fractures in people older than 50 or 75 years. K E Y W O R D S adverse drug reactions, benzodiazepines, drug utilization, pharmacoepidemiology 1 | INTRODUCTION Fractures are a frequent consequence of falls; in older people, they may lead to functional disability, decrease quality of life and autonomy, and even result in death. 1,2 Hip and forearm fractures are the most frequent types resulting from single or repeated falls; shoulder and ankle fractures are less frequent. 3 More than 87% of hip fractures are associated with falls by persons aged 65 years or more. 4 They are associated with a higher risk of mortality in elderly people 5,6 and a decrease in their life expectancy. 7 Strong evidence shows that use of sedative-hypnotic and anxiolytic benzodiazepines (BZD) increases the risk of falls or fractures in older people, 8-11 especially long-acting BZD. 1 Three meta-analyses exploring the association between drug use and falls in older people