GPs can safely reduce the number of antihypertensive medications taken by some older people without substantial changes to blood pressure control, finds new research from the Universities of Oxford, Cambridge and Southampton.
A potential major consequence of lockdown measures introduced to tackle the COVID-19 pandemic is that fewer patients are seeing their doctor for check-ups and management of their chronic conditions.
One area likely to be neglected is polypharmacy – taking multiple medications for multiple conditions – which is common in older people and can be complicated to manage. Polypharmacy cannot be ignored, as it may increase the risk of side effects to medications due to harmful drug interactions. As such, it is generally desirable to prescribe patients the minimum amount of medication needed.
This NIHR funded study, published today in The Journal of the American Medical Association, showed that in some older people it is possible for GPs to reduce the number of blood pressure lowering medications people take with limited impact on their blood pressure control or quality of life. The trial showed over a period of 12 weeks, blood pressure remained well controlled (150 mm Hg or less) in 86.4% of patients in the medication reduction arm and 87.7% of patients in the usual care arm, with two thirds of those in the medication reduction group taking fewer medications at the end of the study.
Dr Jenni Burt, Senior Social Scientist at the University of Cambridge’s Primary Care Unit said: “During this pandemic, it is vital that chronic conditions such as hypertension continue to be managed and medicines reviewed for their appropriateness. More than half of patients aged 80 or older will have high blood pressure, and many of them may be taking two or more different drugs to control it. Since blood pressure medications are prescribed for prevention rather than to alleviate symptoms, they are an ideal target for reducing polypharmacy, particularly when the benefits of continued treatment might not outweigh the harms.”
Dr James Sheppard, University Research Lecturer at Oxford University’s Nuffield Department of Primary Care Health Sciences, and co-chief investigator on the study, said: “Blood pressure medications are proven to reduce a person’s risk of stroke and heart attack, but for some, they may also cause fainting and falls or kidney problems, so called ‘adverse events’. This trial shows that when someone is concerned about the risk of adverse events, it is possible to reduce the number of tablets being taken and still achieve good blood pressure control, which is important for preventing stroke.”
The ‘non-inferiority’ trial – designed to demonstrate that medication reduction is no worse than usual care (continuing all medication) – was conducted in 69 GP surgeries across the Midlands and South of England. Over 550 participants aged 80 years or older with well-controlled blood pressure taking two or more antihypertensives were included in the study. Nearly all (98%) were living with at least 2 chronic conditions, bringing the average number of medications up to four per person.
Prof Richard McManus, a practising GP, professor of Primary Care at Oxford University and co-chief investigator on the study, said: “For clinicians concerned that older patients may be taking too many medications, we’ve shown that in the short term it’s possible to safely reduce the number of antihypertensive medications. However, the impacts of medication reduction for longer than 12 weeks weren’t tested in this study, so healthcare professionals should still exercise caution and use their own clinical judgement when deciding whether or not to deprescribe blood pressure medication.”
Sheppard JP, Burt J, Lown M, et al. Effect of antihypertensive medication reduction vs usual care on short-term blood pressure control in patients with hypertension aged 80 years and older: the OPTIMISE randomized clinical trial. JAMA. 2020; 323(20):1-13. doi:10.1001/jama.2020.4871
The infographic outlining the study and the deprescribing algorithm used is available from:
Lucy Lloyd, Communications, Primary Care Unit