Withdrawal of antihypertensive drugs in older people

Reeve, Emily; Jordan, Vanessa; Thompson, Wade; Sawan, Mouna; Todd, Adam; Gammie, Todd M.; Hopper, Ingrid; Hilmer, Sarah N.; Gnjidic, Danijela

doi:10.1002/14651858.cd012572.pub2

Cited by 63 publications

(86 citation statements)

References 67 publications

(39 reference statements)

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“…No evidence was found regarding the benefits or harms of deprescribing blood pressure‐ or lipid‐lowering medication in people with diabetes. Recently, it was concluded that, for older people with diabetes in general, there is insufficient evidence to make firm conclusions about any positive or negative effects of discontinuing blood pressure‐lowering drugs 39 …”

Section: Discussionmentioning

confidence: 99%

“…Recently, it was concluded that, for older people with diabetes in general, there is insufficient evidence to make firm conclusions about any positive or negative effects of discontinuing blood pressure-lowering drugs. 39 Eligibility criteria for deprescribing varied among the studies but usually included HbA 1c or systolic blood pressure levels below a certain level and/or being at high risk of adverse events. There is still debate about the eligibility criteria for deprescribing.…”

Section: Discussionmentioning

confidence: 99%

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Rates, determinants and success of implementing deprescribing in people with type 2 diabetes: A scoping review

2020

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Background Individualizing goals for people with type 2 diabetes may result in deintensification of medication, but a comprehensive picture of deprescribing practices is lacking. Aims To conduct a scoping review in order to assess the rates, determinants and success of implementing deprescribing of glucose‐, blood pressure‐ or lipid‐lowering medications in people with diabetes. Methods A systematic search on MEDLINE and Embase between January 2007 and January 2019 was carried out for deprescribing studies among people with diabetes. Outcomes were rates of deprescribing related to participant characteristics, the determinants and success of deprescribing, and its implementation. Critical appraisal was conducted using predefined tools. Results Fourteen studies were included; eight reported on rates, nine on determinants and six on success and implementation. Bias was high for studies on success of deprescribing. Deprescribing rates ranged from 14% to 27% in older people with low HbA1c levels, and from 16% to 19% in older people with low systolic blood pressure. Rates were not much affected by age, gender, frailty or life expectancy. Rates were higher when a reminder system was used to identify people with hypoglycaemia, which led to less overtreatment and fewer hypoglycaemic events. Most healthcare professionals accepted the concept of deprescribing but differed on when to conduct it. Deprescribing glucose‐lowering medications could be successfully conducted in 62% to 75% of participants with small rises in HbA1c. Conclusions Deprescribing of glucose‐lowering medications seems feasible and acceptable, but was not widely implemented in the covered period. Support systems may enhance deprescribing. More studies on deprescribing blood pressure‐ and lipid‐lowering medications in people with diabetes are needed.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Rates, determinants and success of implementing deprescribing in people with type 2 diabetes: A scoping review

2020

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“…A growing interest in deprescribing in older multimorbid patients has been fuelled by mounting evidence on the potential harms of polypharmacy over the last two decades (11)(12)(13)(14)27), as evidenced by the changes in the QOF (8). However, these trends have yet to translate into specific guidelines that would equip GPs for stopping preventive medication with the degree of confidence with which they prescribe it (17,31).…”

Section: Comparison With Existing Literaturementioning

confidence: 99%

“…Relevant 'brief reading' includes recommendations on how to recognise and action opportunities for deprescribing (23)(24)(25) and NICE guidance on multimorbidity, none of which offers advice on reducing specific groups of medication, including antihypertensives (26). These reflect the lack of current evidence about the advantages of withdrawing antihypertensive medication (5,12,13,27).…”

Section: Introductionmentioning

confidence: 99%

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

et al. 2020

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Background: Optimal management of hypertension in older patients with multimorbidity is a cornerstone of primary care practice. Despite emphasis on personalised approaches to treatment in older patients, there is little guidance on how to achieve medication reduction when GPs are concerned that possible risks outweigh potential benefits of treatment. Mindlines – tacit, internalised guidelines developed over time from multiple sources – may be of particular importance in such situations. Aim: To explore GPs’ decision-making on deprescribing antihypertensives in multimorbid patients over 80 years old, drawing on the concept of mindlines. Design: Qualitative interview study. Setting: English general practice. Methods: Thematic analysis of face-to-face interviews with a sample of 15 GPs from 7 practices in the East of England, using a chart-stimulated recall approach to explore approaches to treatment for older multimorbid patients with hypertension. Results: GPs are typically confident making decisions to deprescribe antihypertensive medication in older multimorbid patients when prompted by a trigger, such as a fall or adverse drug event. GPs are less confident to attempt deprescribing in response to generalised concerns about polypharmacy, and work hard to make sense of multiple sources (including available evidence, shared experiential knowledge, and non-clinical factors) to guide decision-making. Conclusion: In the absence of a clear evidence base on when and how to attempt medication reduction in response to concerns about polypharmacy, GPs develop ‘mindlines’ over time through practice-based experience. These tacit approaches to making complex decisions are critical to developing confidence to attempt deprescribing, and may be strengthened through reflective practice.

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“…This study described in this protocol aims to look at the safety and efficacy of cardiovascular medication reduction compared to usual care in patients aged 75 years and over. There are existing systematic reviews that examine the clinical outcomes of reducing cardiovascular drugs, but these provide insufficient evidence to support clinical decision making [ 15 – 18 ]. One systematic review focused on the clinical outcomes of the medication reduction intervention itself, without evidence for the effect of individual drug classes [ 15 ].…”

Section: Introductionmentioning

confidence: 99%

The health impacts of preventive cardiovascular medication reduction on older populations: protocol for a systematic review and meta-analysis

et al. 2021

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Background Polypharmacy is inevitable and appropriate for many conditions, but in some cases, it can be problematic resulting in an increased risk of harm and reduced quality of life. There has been an increasing interest to reduce cardioprotective medications in older adults to potentially reduce the risk of harm due to treatment; however, there is no evidence on safety and efficacy to support this practice currently. This paper describes a protocol for a systematic review on the safety and efficacy of reducing cardioprotective medication in older populations. Methods MEDLINE (PubMed), Embase (Ovid), and CENTRAL (Cochrane Central Register of Controlled Trials) will be searched from their inception onwards for relevant studies. Randomised controlled trials and non-randomised studies on interventions (prospective, retrospective cohort, case-control) conducted in older adults (75 years or older) examining reduction of cardioprotective medications will be included. The primary outcome of this study will be all-cause hospitalisation. Secondary outcome variables of interest are all-cause hospitalisation, mortality, quality of life, serious adverse events, major adverse cardiovascular events, falls, fractures, cognitive functioning, bleeding events, renal functioning, medication burden, drug reinstatement, time-in-hospital, and frailty status. Two reviewers will independently screen all citations, full-text articles, and extract data. Confidence in cumulative evidence will be assessed using the GRADE approach; the risk of bias will be assessed by the RoB-II tool for randomised controlled studies and ROBINS-I for non-randomised studies. Where sufficient data are available, we will conduct a random effects meta-analysis by combining the outcomes of the included studies. Sub-group analysis and meta-regression are planned to assess the potential harms and risks of different drug classes and the impacts in different patient populations (e.g. sex, cognitive status, renal status, and age). Discussion The study will be a comprehensive review on all published articles identified using our search strategy on the safety and efficacy of cardioprotective medication reduction in the older population. The findings will be crucial to inform clinicians on potential health outcomes of reducing cardiovascular medication in the elderly. Systematic review registration PROSPERO CRD42020208223

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Withdrawal of antihypertensive drugs in older people

Cited by 63 publications

References 67 publications

Rates, determinants and success of implementing deprescribing in people with type 2 diabetes: A scoping review

Rates, determinants and success of implementing deprescribing in people with type 2 diabetes: A scoping review

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

The health impacts of preventive cardiovascular medication reduction on older populations: protocol for a systematic review and meta-analysis

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