By: Sreemathi Palanisamy, PharmD Candidate 2022, Thara Kottoor, PharmD Candidate 2022, St. Louis College of Pharmacy at University of Health Sciences and Pharmacy in St. Louis
Mentor: Haley N. Johnson, PharmD, BCPS; Assistant Professor, Department of Pharmacy Practice, St. Louis College of Pharmacy at University of Health Sciences and Pharmacy in St. Louis
The general population is aging as 10,000, “Baby Boomers,” are turning 65 years old each day in the United States. It is predicted that older adults will comprise 20% of the population by the year 2030.1 With the increasing geriatric population, the number of patients with age-related chronic conditions is rising, as well. Elderly patients are prescribed multiple medications to control their chronic illnesses, which increases the risk for adverse events, poor adherence, and direct and indirect healthcare costs.
Polypharmacy, the use of at least five medications,is a growing peril as our healthcare system is heavily driven by evidence-based medicine.2 Specifically, antihypertensive medications are commonly prescribed in older populations to prevent strokes and cardiovascular diseases. Although efficacious, the agents can also increase the risk of falls, which could potentially be fatal, induce cognitive decline, and decrease overall quality of life. “Deprescribing,” is a method used to adjust medications to their minimum effective dosage or ceasing therapy if the harm outweighs the benefits of treatment. Although best practice recommendations such as the Beers, STOPP, and START criteria, highlight using clinical judgment and taking a patient-specific approach when prescribing antihypertensives in elderly patients, there has been a lack of data and literature noting the long term effects after antihypertensive medications have been deprescribed in the geriatric population.3,4
The Systolic Blood Pressure Trial (SPRINT) compared two strategies for treating systolic blood pressure (SBP) in reducing the incidence of several cardiovascular events and death, one that targeted a systolic blood pressure (SBP) of <140 mm Hg and another that targeted a more intensive SBP target of <120 mm Hg. Patients who were 50 years or older, had an average baseline SBP ≥ 130 mmHg, and at high cardiovascular risk were included in the study. Although higher rates of adverse events were observed in the intensive treatment group, the study supported an intensive treatment for a target SBP of 120 mm Hg for a significant 34% reduction in fatal and CVD events compared to patients who were treated with a SBP target of 140 mmHg.5 These results were consistent among all the age groups that participated in the study, including patients who are 75 year of age or older. However, the SPRINT trial did not include geriatric patients with multiple comorbidities including diabetes, dementia, stroke, and other conditions that would reduce participants’ life expectancy, so the study is limited by its lack of generalizability to patients who may experience more adverse events with intensive blood pressure goals.
Even though medication de-escalation is believed to attenuate efficacy, research has shown that adequate hypertension management can be achieved with fewer drug interventions. Specifically, the Hypertension in Very Elderly Trial (HYVET) found that the antihypertensive indapamide (a thiazide-like diuretic), with or without perindopril (an angiotensin-converting enzyme inhibitor), was beneficial in reducing the risk of fatal or nonfatal stroke, heart failure, and death from stroke or any cause in patients aged 80-89 years old treated to a target blood pressure of 150/80 mm Hg.6 However, the HYVET trial had extensive exclusion criteria, excluding patients with dementia, renal failure, and nursing home residents. 6 Thus, the narrowed participant pool does limit the external validity of the trial’s applicability to a wide range of elderly patients.
According to the Optimizing Treatment for Mild Systolic Hypertension in Elderly (OPTIMISE) randomized control trial, patients 80 years and older are able to maintain their blood pressure goal with antihypertensive de-escalation via removal of one drug. The randomized, non-inferiority, multicenter study included 569 patients who were aged 80 years and older, had a SBP lower than 150 mm Hg at baseline, and were prescribed at least two antihypertensive medications. Patients were allocated in a 1:1 ratio to the intervention group, or de-escalation group, by removing one antihypertension medication, or the control group, in which patients were continued on their current regimens. The OPTIMISE study highlighted that medication reduction is efficacious to standard therapy as the mean SBP in the intervention group and usual care group were 133.7 mmHg and 130.8 mmHg, respectively.7 The trial only evaluated the benefits of antihypertensive reduction over a 12 week period, so it is not conclusive of long-term clinical outcomes. Additionally, the study was conducted in an unblinded manner, with primary care providers allocating patients to medication de-escalation vs. the control group based on their clinical assessments, decreasing the study’s overall internal validity.The study also focused on a narrow spectrum of patients, 80 years and older, which is not representative of the overall geriatric population. 7 Despite the study’s methodology, the OPTIMISE trial was able to support a “less is more” approach in antihypertensive management in geriatric patients.
The SPRINT, HYVET, and OPTIMISE trials focused on patients with antihypertensive medications in outpatient settings. However, elderly patients are often prescribed intensified blood pressure regimens to manage their cardiovascular health upon discharge after hospitalizations. Anderson and colleagues conducted a study that looked at clinical outcomes after intensifying antihypertensive therapies upon discharge for geriatric patients who were hospitalized for pneumonia, urinary tract infection, and venous thromboembolism. The retrospective study included patients 65 years and older with hypertension admitted to Veterans Affairs (VA) health systems over a two-year period. Discharge with antihypertensive intensification was defined as receiving a prescription at discharge for a new or at least 20% higher-dose of antihypertensive medication than what was used prior to admission.8 The study found that in patients admitted to the hospital for non-cardiac causes, adding an additional antihypertensive was associated with increased risk of hospital readmissions and serious adverse events rather than improvements in blood pressure and fewer cardiac events following discharge.8 The trial primarily consisted of older male patients hospitalized for non-cardiac events, which is not applicable to all hospitalized elderly patients. Nevertheless, the study highlights the insignificance and potential harm in intensifying antihypertensives in elderly patients during hospital admissions.
Even though deprescribing antihypertensives is an area in geriatric medicine with lack of robust research, current studies suggest that de-escalating antihypertensive regimens has a positive impact on elderly patients’ quality of life. Geriatric patients are susceptible to medication-related adverse events due to their declining health, so it is rational to provide them with treatment regimens with adequate therapeutic benefits, minimal toxicities, and cost-effectiveness. Based on the current body of literature, it may be more beneficial to have patients on stable and consistent regimens and with close monitoring and follow-up rather than regularly intensifying antihypertensive therapy. Additionally, the inpatient data on antihypertensive escalation at discharge suggests that it is imperative not to modify chronic disease treatments in inpatient settings considering patients’ likelihood of benefit and the interplay of acute hospital conditions. Thus, clinicians should be cognizant of fluctuating blood pressure values which may be transient in the inpatient setting and should not always make medication adjustments accordingly.9
Pharmacists, specifically, can play a major role in optimizing elderly patients’ antihypertensive medication regimens. Specifically, pharmacists can aid in patients’ transitions of care between inpatient and outpatient settings by performing medication reconciliations to evaluate patients’ likelihood of benefiting from medication reduction. 10 Ambulatory care and community pharmacists can also be proactive in the deprescribing process by having conversations with elderly adults about their medications and consulting with patients’ primary care providers about possibly deprescribing antihypertensive medications.11 Overall, based on current data, pharmacists should feel empowered to have conversations about deprescribing with older patients and healthcare professionals to improve health outcomes in the geriatric population and combat polypharmacy.