英国牛津大学Richard J. McManus团队探讨了减少降压药对80岁以上高血压患者短期血压控制的影响。该成果发表在2020年5月26日出版的《美国医学会杂志》上。

当持续治疗弊大于利时，建议对一些服用多药和有多发病的老年患者停用抗高血压药物。

为了确定减少降压药物后，在12周的随访期间，收缩压是否发生明显改变以及不良事件的发生情况，研究组在英格兰的69个初级保健机构进行了一项随机、非盲、非劣效性试验，2017年4月至2018年9月，招募了569例初级保健医生认为可适当减药、年龄超过80岁、收缩压低于150 mmHg、且至少服用2种降压药的患者。将其按1：1随机分组，其中282例减少1种降压药（干预组），287例药物不变，接受常规治疗（对照组）。

569例患者的平均年龄为84.8岁，女性占48.5%，有534例完成了试验。干预组中有229例（86.4%）患者在12周时收缩压低于150 mmHg，对照组中有236例（87.7%）。两组间在预定的7个次要指标中，有5个没有显著差异。在第12周时，有187名（66.3％）的参与者继续减药治疗。与对照组相比，干预组的收缩压平均高出3.4 mmHg。干预组中有12名（4.3%）参与者至少发生1次严重不良事件，对照组中有7名（2.4%）。

总之，对于接受多种降压药物治疗的老年患者，减药治疗在12周收缩压控制方面并不逊于常规治疗。

附：英文原文

Title: Effect of Antihypertensive Medication Reduction vs Usual Care on Short-term Blood Pressure Control in Patients With Hypertension Aged 80 Years and Older: The OPTIMISE Randomized Clinical Trial

Author: James P. Sheppard, Jenni Burt, Mark Lown, Eleanor Temple, Rebecca Lowe, Rosalyn Fraser, Julie Allen, Gary A Ford, Carl Heneghan, F. D. Richard Hobbs, Sue Jowett, Shahela Kodabuckus, Paul Little, Jonathan Mant, Jill Mollison, Rupert A. Payne, Marney Williams, Ly-Mee Yu, Richard J. McManus

Issue&Volume: 2020/05/26

Abstract: Importance  Deprescribing of antihypertensive medications is recommended for some older patients with polypharmacy and multimorbidity when the benefits of continued treatment may not outweigh the harms.

Objective  This study aimed to establish whether antihypertensive medication reduction is possible without significant changes in systolic blood pressure control or adverse events during 12-week follow-up.

Design, Setting, and Participants  The Optimising Treatment for Mild Systolic Hypertension in the Elderly (OPTIMISE) study was a randomized, unblinded, noninferiority trial conducted in 69 primary care sites in England. Participants, whose primary care physician considered them appropriate for medication reduction, were aged 80 years and older, had systolic blood pressure lower than 150 mm Hg, and were receiving at least 2 antihypertensive medications were included. Participants enrolled between April 2017 and September 2018 and underwent follow-up until January 2019.

Interventions  Participants were randomized (1:1 ratio) to a strategy of antihypertensive medication reduction (removal of 1 drug [intervention], n=282) or usual care (control, n=287), in which no medication changes were mandated.

Main Outcomes and Measures  The primary outcome was systolic blood pressure lower than 150 mm Hg at 12-week follow-up. The prespecified noninferiority margin was a relative risk (RR) of 0.90. Secondary outcomes included the proportion of participants maintaining medication reduction and differences in blood pressure, frailty, quality of life, adverse effects, and serious adverse events.

Results  Among 569 patients randomized (mean age, 84.8 years; 276 [48.5%] women; median of 2 antihypertensive medications prescribed at baseline), 534 (93.8%) completed the trial. Overall, 229 (86.4%) patients in the intervention group and 236 (87.7%) patients in the control group had a systolic blood pressure lower than 150 mm Hg at 12 weeks (adjusted RR, 0.98 [97.5% 1-sided CI, 0.92 to ∞]). Of 7 prespecified secondary end points, 5 showed no significant difference. Medication reduction was sustained in 187 (66.3%) participants at 12 weeks. Mean change in systolic blood pressure was 3.4 mm Hg (95% CI, 1.1 to 5.8 mm Hg) higher in the intervention group compared with the control group. Twelve (4.3%) participants in the intervention group and 7 (2.4%) in the control group reported at least 1 serious adverse event (adjusted RR, 1.72 [95% CI, 0.7 to 4.3]).

Conclusions and Relevance  Among older patients treated with multiple antihypertensive medications, a strategy of medication reduction, compared with usual care, was noninferior with regard to systolic blood pressure control at 12 weeks. The findings suggest antihypertensive medication reduction in some older patients with hypertension is not associated with substantial change in blood pressure control, although further research is needed to understand long-term clinical outcomes.

DOI: 10.1001/jama.2020.4871

Source: https://jamanetwork.com/journals/jama/article-abstract/2766421