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, although long term safety of deprescribing still needs to be established.
Key messages for clinicians and healthcare commissioners
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, according to this NIHR funded study, published in The Journal of the American Medical Association, June 2020.
Dr Amrit Takhar, GP and Clinical Lead for Cardiology at Cambridgeshire and Peterborough Clinical Commissioning Group, said: “In clinical practice and drug research it is common to ADD drugs, so it was refreshing to take part in this groundbreaking study, which has shown that it is possible to STOP drugs safely in this patient group. We found that patients were very happy to engage with this study. They were interested in the possibility of reducing medications and the potential for reduced side effects and the problems with medication interactions that become more common in older patients.”
Clinicians will remain cautious in stopping medication until we see the longer term effects of this, as the study only monitored patients for 12 weeks. As we move to more patient self monitoring, it may become easier to advise patients on their medication options.” – Dr Amrit Takhar, GP, clinical lead, cardiology, Cambridgeshire and Peterborough CCG
Why this research was needed
Polypharmacy – taking multiple medications for multiple conditions – 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.
Blood pressure medications, the focus of this trial, are known to reduce a person’s risk of stroke and heart attack, but for some, they may also cause ‘adverse events’ including fainting and falls or kidney problems.
Dr Jenni Burt, Senior Social Scientist at the University of Cambridge’s Primary Care Unit and co- chief investigator on this study, said: “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.”
What did the researchers do?
This ‘non-inferiority’ trial was designed to demonstrate that medication reduction is no worse than usual care (continuing all medication). The trial 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. Participants were divided into two groups: one received care that included medication reduction and the other received usual care.
What did the research find?
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.
The research indicates that when a clinician 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, explained Dr James Sheppard, University Research Lecturer at Oxford University’s Nuffield Department of Primary Care Health Sciences, and co-chief investigator on the study.
Read the research
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:
Find resources on polypharmacy
NICE Guidance Multimorbidity and polypharmacy. Key therapeutic topic [KTT18] Published date: 16 January 2017 Last updated: 01 September 2019