"Doctor, can you take away any of my medications? I am taking too many pills."
As physicians, we hear this request frequently. The population most affected by the issue of being prescribed multiple medications, known as polypharmacy, is the elderly. Trying to organize long lists of medications, and remembering to take them exactly as prescribed, can become a full-time job. In addition to the physical and emotional burden of organizing medications, older adults are at increased risk for certain types of side effects and potential worse outcomes due to polypharmacy.
A common source of prescriptions is high blood pressure, with older adults often finding themselves on multiple medications to lower their blood pressure. Data from the Framingham Heart Study show that over 90% of middle-aged people will eventually develop high blood pressure, and at least 60% will go on to take medications to lower blood pressure.
The OPTIMISE trial, recently published in JAMA, studied the effect of reducing the number of blood pressure medications, also known as deprescribing, in the elderly.
How low should blood pressure be in older adults?
Previous large studies, including the HYVET trial and the more recent SPRINT trial, have shown that treatment of high blood pressure in older adults remains important, and may reduce the risk of heart attack, heart failure, stroke, and cardiovascular death. Black adults made up 31% of the SPRINT trial study population; therefore, study results could be used to make recommendations for this population, which is at increased risk for high blood pressure. However, many groups of older people were excluded, including nursing home residents, those with dementia, diabetes, and other conditions common in more frail older adults.
The most recent guidelines from the American College of Cardiology (ACC) and the American Heart Association (AHA), published in 2017, define optimal blood pressure as less than 120/80 for most people, including older adults age 65 or above. They recommend a target of 130/80 for blood pressure that is treated with medication. The 2018 guidelines from the European Society of Cardiology (ESC) and the European Society of Hypertension (ESH) recommend a more relaxed goal of less than 140/90.
The US and European populations differ in their risk for cardiovascular disease, with the US population generally considered at higher risk for strokes, heart failure, and heart attacks, so it might be appropriate to have different blood pressure goals for these two groups. Regardless, both groups acknowledge that factors such as frailty, limited life expectancy, dementia, and other medical issues should be considered when developing individualized goals for patients.
What happened to older patients whose blood pressure medications were reduced?
The OPTIMISE trial provided preliminary evidence that some older adults may be able to reduce the number of blood pressure medications they take, without causing a large increase in blood pressure. For the trial, researchers randomized 569 patients age 80 or older, with systolic blood pressure lower than 150 mm Hg, to either remain on their current blood pressure medications, or to remove at least one blood pressure medication according to a prespecified protocol. The study subjects were followed for 12 weeks to assess blood pressure response.
Researchers found that both the people who remained on their previous blood pressure medications and those who reduced the number of medications had similar control of blood pressure at the end of the study. While the mean increase in systolic blood pressure for the group that reduced medications was 3.4 mm Hg higher than the control group, the number of patients who had systolic blood pressure below the goal of 150 mm Hg at the end of the study was not significantly different between groups. Approximately two-thirds of patients were able to remain off the medication at the end of the study.
It is important to note that OPTIMISE is relatively a small study, and the investigators did not examine long-term outcomes such as heart attack, heart failure, or stroke for this study (as the HYVET and SPRINT trials did), so we don't know what the long-term effect of deprescribing would be.
More research needed to examine long-term effects of deprescribing
While the OPTIMISE trial was promising, larger and longer-duration trials looking at outcomes beyond blood pressures alone are necessary to really know whether deprescribing is safe in the long term. Additionally, these researchers used a target systolic blood pressure of less than 150 mm Hg, which is higher than the most recent ACC/AHA and ESC/ESH recommendations.
An interesting aspect of this study design is that the primary care physician had to feel that the patient would be a good candidate for deprescribing. This left room for physicians, who may know patients well, to individualize their decisions regarding deprescribing.
The bottom line
This trial gives doctors and other prescribers some support when considering a trial of deprescribing a blood pressure medication for select older patients, with a goal to improve quality of life. These patients must be closely followed to monitor their responses.
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