Discontinuing Antihypertensive Drugs in Adults 50 Years and Older

Can antihypertensive drugs be safely discontinued in adults 50 years and older without increasing the risk of major adverse health outcomes, such as death, stroke, or hospitalization?

Discontinuing antihypertensive drugs in adults 50 years and older may lead to a modest increase in blood pressure but does not significantly increase the risk of all-cause mortality, stroke, myocardial infarction, or hospitalization rates.¹ (Strength of Recommendation: B, limited-quality patient-oriented evidence.)

Antihypertensive drugs are effective in reducing cardiovascular disease, end-stage kidney disease, and all-cause mortality; however, they can cause adverse effects and contribute to polypharmacy in adults.² Withdrawing, or deprescribing, antihypertensive drugs may reduce adverse effects, particularly in older adults who are more prone to adverse effects and the risks associated with polypharmacy.³

This Cochrane review included six randomized controlled trials that evaluated the clinical impact of discontinuing vs continuing antihypertensive drugs in adults 50 years and older (mean age = 58–82 years) who were taking them for hypertension or for the primary prevention of cardiovascular disease.¹ A lower age threshold of 50 years was selected to include older studies and broaden applicability to clinical circumstances where earlier-than-expected aging may be relevant. Patients were excluded if their antihypertensive drugs were prescribed for secondary prevention after diagnoses (eg, with myocardial infarction, heart failure, chronic kidney disease).

The trials cumulatively enrolled 1,073 participants and were conducted within the United States, the Netherlands, the United Kingdom, and Canada.¹ Discontinuation was immediate or a gradual taper with follow-up for 4 to 56 weeks. The main outcome measures were blood pressure level and all-cause mortality, stroke, myocardial infarction, and hospitalization rates.

Patients who discontinued antihypertensive therapy through gradual tapering or immediate cessation saw an increase in average systolic blood pressure of 9.75 mm Hg (95% CI, 7.33–12.18) and an increase in diastolic blood pressure of 3.5 mm Hg (95% CI, 1.82–5.18), compared with patients who continued taking antihypertensives.¹ There was no increase in all-cause mortality or stroke rates in patients who discontinued anti-hypertensives compared with patients who continued antihypertensives. These outcomes were supported by low-certainty evidence. Withdrawing antihypertensives was also not associated with a significant increase in myocardial infarction or hospitalization rates, supported by very low-certainty evidence and low-certainty evidence, respectively.

This review had many notable limitations.¹ Primarily, there was a small number of mostly older trials with methodologic weaknesses (eg, small sample sizes, wide-ranging patient ages, lack of blinding, incomplete follow-up, selective outcome reporting). Event rates for key outcomes such as all-cause mortality, myocardial infarction, and stroke were very low, leading to wide CIs and considerable variability in results across trials.

The American Geriatrics Society Beers Criteria include anti-hypertensives among the drugs that should be used cautiously in adults 65 years and older and support careful deprescribing in older or high-risk populations.⁴ The STOPP/START (Screening Tool of Older Persons' Prescriptions/Screening Tool to Alert to Right Treatment) criteria offer structured guidelines for discontinuing and initiating drugs in patients 65 years and older who may be experiencing polypharmacy and adverse events.⁵

The practice recommendations in this activity are available at https://www.cochrane.org/CD012572.