Authors:
Keturah Weaver Pharm D, BCPS
Daniel Longyhore Pharm D, M.S., BCACP
Reviewers:
Sara Wettergreen, PharmD, BCACP
J. Ben Hill, PharmD
Kristin Rieser, PharmD, BCACP
The Problem
How often do you recommend stopping a medication being used for a stable chronic condition? Health care professionals often don’t think twice about adding a new medication when a patient is not at goal. But we’re reluctant to stop a medication for a chronic condition when the patient appears to be stable and doing well. Does the patient have high cholesterol? Add a statin. Does the patient have type 2 diabetes? It’s time to start metformin. Is the patient’s blood pressure at target? Let’s discontinue one of their medications…what? Polypharmacy in older adults is a significant problem. It’s costly and increases the likelihood of adverse effects. Several observational studies have suggested that lower blood pressure and multiple antihypertensive medications may be harmful in the elderly.1-3 Is it possible to discontinue medications without causing serious harm?
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With the disclaimer that the following comments come from an old, retired (and out of date) clinician, here are a few issues related to the case that was discussed in this session:
1. The very wide pulse pressure and low DBP raise the issues: (a) the mean arterial pressure may be rather low and especially so if the patient is bradycardic. If the patient has a “correctable” bradycardia – as may result from some calcium blockers – correcting the bradycardia may reduce preload and SBP. (b) the wide pulse pressure also suggests “stiff arteries” which may indicate arterial calcification which, in turn, can cause may pseudohypertension. The “Osler maneuver” may distinguish true vs pseudo HTN if one has the clinical skill to perform that test.
2. Some authorities have recommended using sitting and standing BP measurements in the elderly and to rely on standing pressures if the two differ by more than 5 to 10 mm Hg. The logic being that the elderly are more subject to orthostatic hypotension and falls which may be avoided if standing BPs are used.