De-intensify Anti-Hypertensives for Nursing Home Residents? Athanase Benetos and Mike Steinman

A few weeks ago, I was skimming this NEJM paper for UCSF's Division of Geriatrics Journal club on de-prescribing anti-hypertensive medications for older adults in nursing homes. Seemed to make a world of sense. The study found no difference between the deprescribing arm and the usual care arm in mortality, the primary study outcome. I thought, great! So we can deprescribe anti-hypertensives without changing mortality, that must be what the authors concluded.

I was shocked, therefore, to read in the first paragraph of the discussion that the deprescribing arm did not achieve the hypothesized 25% reduction in mortality.  What?!?  Why would deprescribing be associated with reduced mortality? That's not the main reason or even the first reason I think of for deprescribing.  Reducing side effects that impair quality of life, sure. Less pill burden, of course.  But prolonged life?  Seemed a stretch.

Today we hear from the first author of this study, Athanase Benetos, an esteemed geriatrician-researcher from France.  For context, we also interviewed Mike Steinman, co-chair of the Beers criteria and co-lead of the US Deprescribing Research Network.

We learned about:

• Why the hypothesis of reduced mortality in deprescribing was justified, based on natural decreases in blood pressure with aging, and the Partridge study, an observational study that found higher risks of mortality associated with using multiple anti-hypertensive and low blood pressure.

• Why mortality was chosen as the primary outcome.

• Is a negative superiority study the same as what they might have found in a non-inferiority study? (stay with us)

• Variation in outcome by frailty status

• How to place this study in context with other research, such as the Danton study mentioned on a recent podcast about deprescribing near the end of life. Dantos was a study of deprescribing for nursing home residents with dementia that was stopped early due to safety concerns. Other studies for context include Sprint, Optimize, and an observational study by Bocheng Jing (UCSF statistician in our group).

At the end, we ask our guests to put it together. With all that we know at this point, what's a clinician to do? To deprescribe or not to deprescribe?

And, zoot alors! I get to sing Hymne A L'amour in French! Athanase recounts the moving story of how Edith Piaf sang this song the night she learned the man she loved, Marcel Cerdan, died in a plane crash.

-Alex Smith