Primary care physicians only deintensified treatment for about a quarter of older adults whose hypertension or diabetes treatment resulted in a low blood pressure or HbA1c, a recent study showed.
The retrospective cohort study used data from the Department of Veterans Affairs (VA) to assess both hypertension and blood glucose medication deintensification (i.e., dosage reduction or withdrawal of a drug). The 2 cohorts included all active primary care patients 70 years and older with diabetes who in 2012 received treatment for hypertension or hyperglycemia. Results were published online on Oct. 26 by JAMA Internal Medicine.
Researchers stratified the 2 cohorts based on index blood pressure (BP) or HbA1c: very low (BP under 120/65 mm Hg or HbA1c under 6%), moderately low (120 to 129 mm Hg systolic or diastolic less than 65 mm Hg or HbA1c of 6.0% to 6.4%), not low, and high. Patients were considered eligible for active deintensification of therapy if their BP or HbA1c were classified in any low category. In patients whose BP or HbA1c was not low, deintensification of therapy was considered to represent baseline rates of medication discontinuation due to attrition of medications, adverse reactions, patient-driven discontinuation, or medication nonadherence.
The BP cohort included 211,667 participants. In 104,486 patients with BP levels that were not low, treatment was deintensified in 15.1% (95% CI, 14.9% to 15.4%), compared to 16% (95% CI, 15.5% to 16.4%) of 25,955 patients with moderately low BP levels and 18.8% (95% CI, 18.5% to 19.1%) of 81,226 patients with very low BP levels.
The HbA1c cohort had 179,991 participants. In 143,305 patients who had HbA1c levels that were not low, treatment was deintensified in 17.5% (95% CI, 17.3% to 17.7%), compared to 20.9% (95% CI, 20.3% to 21.4%) of 23,769 patients with moderately low HbA1c levels, and 27% (95% CI, 26.2% to 27.8%) of 12,917 patients with very low HbA1c levels.
The researchers found treatment deintensification to be only weakly associated with a patient's BP or HbA1c level and predicted life expectancy. This suggests that “physicians are generally reluctant to deintensify treatment even in conditions that make benefits of therapy limited in comparison with potential harms,” according to an accompanying editorial.
The editorial proposed using available vulnerability indicators, such as a comprehensive geriatric assessment, to appropriately balance risks and benefits for vascular risk factor prevention in vulnerable patients. “This kind of approach would increase the number of clinical assessments for vulnerable individuals along with a possible increase in costs, but this increase could be counterbalanced by savings from a decreased number of prescriptions and the expected reduction of adverse events,” the editorialist wrote.
The study's authors noted limitations of their analysis, such as how pharmacy records underestimate medication intensity for patients who receive medications outside the VA and how some patients with transiently low BP or HbA1c levels may not require deintensification.