Less Might Be More

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My philosophy on prescribing medication has always been that less is better. I always prefer to see patients treat themselves. For example, when I see someone who is overweight and who develops mild diabetes or hypertension, my preference is always to try to get him or her to lose weight rather than start on medication. One of the reasons for my approach to this is that medications can have side effects. Unfortunately, however, urging someone to lose weight or alter their diet or behavior often does not work because of human nature. Recently, a study was published that looked at the effects of deprescribing (i.e. stopping) medications in older (>80) individuals.

High blood pressure is the leading modifiable risk factor for heart disease and the most common condition in older people with multimorbidity (multiple diseases). Antihypertensive medication prevents strokes and heart disease in older, high-risk patients, and about half of people 80 and over are on these medications. But some observational studies have shown that lower blood pressure and multiple antihypertensive medications may be harmful in some older patients with polypharmacy (multiple meds) and multimorbidity. Guidelines recommend using clinical judgement when prescribing medications in frail, older patients and they emphasize a personalized approach that might include attempts to improve quality of life by deprescribing, however the guidelines are based largely on expert opinion and are vague. There have been few studies published that looked at the safety and efficacy of antihypertensive medication reduction in routine clinical practice, which is why this new study is groundbreaking.

This study, done in the UK, aimed to establish whether partial medication reduction is possible without clinically significant changes in blood pressure control, quality of life, adverse events, serious adverse events, and a change in systolic and diastolic blood pressure over a 12-week period. Participants in the trial were aged 80 and over, on two or more antihypertensive agents, and had multiple morbidities. Unlike previous studies that were observational, this study was a randomized controlled trial with a control group. What it demonstrated was that deprescribing antihypertensive medications did not cause any significant adverse events as compared to the control group, although the study group did see a small rise in systolic blood pressure. Proponents of deprescribing suggest potential benefits could be an improved quality of life, reduced adverse effects, and a reversal of cognitive decline (age-related dementia). Quality of life improvements and reversal of cognitive decline could not be measured in this study because it was too short (12 weeks). But it does plant a seed to justify a longer study which might measure these factors.

On a final note, patients should never adjust the dosage of their medications or discontinue medications on their own. This should always be done under the supervision of a clinician. However, this study may lend credence to the old adage “less is more.”

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 By Peter Galvin, MD

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