The use and discontinuation of antihypertensive medication in patients with limited life expectancy

Owing to the wide range of medications prescribed to manage acute symptoms associated with life limiting illness and those used to treat or prevent other long-term conditions, polypharmacy is commonly observed amongst patients with limited life expectancy. This can be problematic for several reasons: firstly, patients who take five or more medications per day are more likely to become non-adherent with their medication; secondly, possibly as a result of non-adherence, treatment targets are rarely achieved among patients with limited life expectancy using preventative medication; and, thirdly, as the pharmacokinetic and pharmacodynamics parameters of patients with limited life expectancy are constantly changing (e.g. variation in volume of distribution or altered drug excretion due to declining renal and/or hepatic function), the risk of developing drug-related toxicity due to drug-drug interactions is increased.

Therefore, as a consequence of the potential for polypharmacy to cause harm, medication use among patients with limited life expectancy should be appropriate, regularly evaluated and optimised to align with achievable therapeutic outcomes that consider the remaining life expectancy of the patient. To date, however, there is a growing body of evidence that suggests medication continues to be prescribed inappropriately for patients with limited life expectancy.

Our previous work has shown that patients requiring specialist palliative care take many inappropriate medications in view of their life limiting diagnosis. These medications not only increase the pill burden for the patient but also increase the risk of developing a drug-related toxicity through drug-drug and drug-disease interactions. Indeed, one of the most commonly prescribed inappropriate medications that contribute to drug-drug interactions are those used for the treatment of hypertension. This medication is largely considered inappropriate for this patient group, as it can take several years to have time until benefit on reducing cardiovascular and cerebrovascular related events. However, many patients with limited life expectancy also lose weight as a consequence of their illness – possibly reducing their blood pressure. When this occurs, it poses the obvious question – is the antihypertensive medication still required?

It is, therefore, not clear when antihypertensive medication should be used in patients with limited life expectancy and, when it is no longer indicated, how and when should it be discontinued. This work seeks to address these questions and will establish an evidence-based role for antihypertensive medication in managing hypertension in patients with limited life expectancy.

Key objectives:
(1) Determine the incidence of inappropriate antihypertensive medication use amongst patients with limited life expectancy.
(2) Establish the blood pressure of such patients before and after cessation of antihypertensive medication.
(3) Explore patients’ views and experiences of using and discontinuing their antihypertensive medication.