Effect of Antihypertensive Medication Reduction vs Usual Care on Short-term Blood Pressure Control in Patients With Hypertension Aged 80 Years and Older

Abstract

IMPORTANCE Deprescribing of antihypertensive medications is recommended for some older patients with polypharmacy and multimorbidity when the benefits of continued treatment may not outweigh the harms.OBJECTIVE This study aimed to establish whether antihypertensive medication reduction is possible without significant changes in systolic blood pressure control or adverse events during 12-week follow-up. DESIGN, SETTING, AND PARTICIPANTSThe Optimising Treatment for Mild Systolic Hypertension in the Elderly (OPTIMISE) study was a randomized, unblinded, noninferiority trial conducted in 69 primary care sites in England. Participants, whose primary care physician considered them appropriate for medication reduction, were aged 80 years and older, had systolic blood pressure lower than 150 mm Hg, and were receiving at least 2 antihypertensive medications were included. Participants enrolled between April 2017 and September 2018 and underwent follow-up until January 2019.INTERVENTIONS Participants were randomized (1:1 ratio) to a strategy of antihypertensive medication reduction (removal of 1 drug [intervention], n = 282) or usual care (control, n = 287), in which no medication changes were mandated. MAIN OUTCOMES AND MEASURESThe primary outcome was systolic blood pressure lower than 150 mm Hg at 12-week follow-up. The prespecified noninferiority margin was a relative risk (RR) of 0.90. Secondary outcomes included the proportion of participants maintaining medication reduction and differences in blood pressure, frailty, quality of life, adverse effects, and serious adverse events. RESULTS Among 569 patients randomized (mean age, 84.8 years; 276 [48.5%] women; median of 2 antihypertensive medications prescribed at baseline), 534 (93.8%) completed the trial. Overall, 229 (86.4%) patients in the intervention group and 236 (87.7%) patients in the control group had a systolic blood pressure lower than 150 mm Hg at 12 weeks (adjusted RR, 0.98 [97.5% 1-sided CI, 0.92 to ϱ]). Of 7 prespecified secondary end points, 5 showed no significant difference. Medication reduction was sustained in 187 (66.3%) participants at 12 weeks. Mean change in systolic blood pressure was 3.4 mm Hg (95% CI, 1.1 to 5.8 mm Hg) higher in the intervention group compared with the control group. Twelve (4.3%) participants in the intervention group and 7 (2.4%) in the control group reported at least 1 serious adverse event (adjusted RR, 1.72 [95% CI, 0.7 to 4.3]).CONCLUSIONS AND RELEVANCE Among older patients treated with multiple antihypertensive medications, a strategy of medication reduction, compared with usual care, was noninferior with regard to systolic blood pressure control at 12 weeks. The findings suggest antihypertensive medication reduction in some older patients with hypertension is not associated with substantial change in blood pressure control, although further research is needed to understand long-term clinical outcomes.

GPs’ mindlines on deprescribing antihypertensives in older patients with multimorbidity: a qualitative study in English general practice

“…This qualitative study took place as part of the OPTiMISE (OPtimising Treatment for MIld Systolic hypertension in the Elderly) trial, whose goal was to compare a strategy of antihypertensive medication reduction with usual care for multimorbid older (≥80 years) patients in primary care (42). The aim was to explore how GPs' make decisions about prescribing and deprescribing antihypertensives in multimorbid older patients, within everyday clinical practice.…”

Deprescribing antihypertensives in patients with multimorbidity

“…Patients with a history of heart failure, myocardial infarction/stroke in the preceding 12 months, secondary hypertension or lacking in capacity to consent were excluded from the trial. 9 Participants were randomised to either medication reduction or usual care. The choice of drug for withdrawal was made prior to randomisation by the primary care physician.…”

“…Trial follow-up lasted for 12 weeks, and outcomes included between-group differences in blood pressure control (primary outcome), mean blood pressure, quality of life, frailty, sideeffects, adverse events (post hoc outcome) and serious adverse events. 9 The trial was designed to determine whether medication reduction was equivalent (or 'non-inferior') to usual care. The primary outcome was measured as a relative risk (RR), and an RR of close to 1.00 would mean blood pressure control was almost exactly the same in both groups.…”

“…The Optimising Treatment for Mild Systolic Hypertension in the Elderly (OPTIMISE) study 9 was recently published in the Journal of the American Medical Association and examined the short‐term safety and efficacy of antihypertensive deprescribing. The trial was limited to withdrawal of one antihypertensive medication, an intervention termed ‘medication reduction’.…”

“…Patients were eligible if they were aged 80 years or older, with systolic blood pressure at baseline <150mmHg and prescribed two or more antihypertensive treatments for at least 12 months prior to enrolment. Patients with a history of heart failure, myocardial infarction/stroke in the preceding 12 months, secondary hypertension or lacking in capacity to consent were excluded from the trial 9 …”