NEW YORK - Most, but not all, guideline-recommended drugs and their combinations yield modest survival benefits in older adults with multiple chronic medical conditions, researchers report.
"Until there is better evidence in older adults with multiple chronic conditions, clinicians need to take a more thoughtful and nuanced approach to medication prescribing," Dr. Mary E. Tinetti from Yale School of Medicine, New Haven, Connecticut said by email. "This is particularly supported by the fact that outside of perhaps anticoagulation for atrial fibrillation, the magnitude of benefit for most of these medications is quite modest."
Nearly 40% of adults 65 years and older take at least five prescription medications, but the benefits of drugs prescribed for a single condition are difficult to ascertain in the
presence of multiple conditions and drugs.
Dr. Tinetti and colleagues used data from the Medicare Current Beneficiary Survey to estimate the association between nine guideline-recommended and commonly prescribed drugs and death in more than 8,500 Medicare participants (mean age, 77.4 years).
The nine drugs included beta-blockers; calcium channel blockers; clopidogrel; metformin; renin-angiotensin system (RAS) blockers; selective serotonin reuptake inhibitors (SSRIs) and selective serotonin norepinephrine reuptake inhibitors (SNRIs); statins; thiazide diuretics; and warfarin.
The most common medical conditions included hypertension, hyperlipidemia, diabetes, and coronary artery disease, the researchers report in The BMJ, online Oct. 2. More than half of the participants took at least three of the nine study drugs, and the mean number of total drugs was 10.0.
The benefits on survival of beta-blockers, calcium channel blockers, RAS blockers, statins, and warfarin were comparable to those reported in randomized controlled trials, although for beta-blockers and warfarin they varied according to coexisting conditions.
Clopidogrel, metformin, and SSRIs/SNRIs, however, were not associated with survival benefits.
The association between drug use and mortality risk was generally similar across patterns of coexisting conditions, suggesting to the researchers "that benefits often remain despite comorbidity."
"Research focused on identifying the medications that have the greatest benefit (defined by patient's outcomes priority such as improved symptoms, optimal physical or cognitive function, or survival) and least harm for key subpopulations of individuals with varying combinations of coexisting conditions should be a top priority," Dr. Tinetti said. "Ironically, although these are the major users of health care, they have largely been ignored in research."
"Many individuals, although they have many conditions, only one or two are really affecting the outcomes that matter most to them," Dr. Tinetti said. "Therefore, medication regimens can be simplified by eliminating medications for conditions that are not likely to benefit the individuals outcome priority, such as improved symptoms, optimal physical or cognitive function, or simplified treatment regimens."
"We know that about one in five individuals are currently receiving guideline-recommended medications for one condition that may be harming another," Dr. Tinetti concluded. "A careful medication review will review these potential offending medications. Given the marginal benefit of each individual medication, and the importance of avoiding harm, potentially offending medications should be discontinued."
Dr. Una Makris from UT Southwestern Medical Center and Dallas VA Medical Center has reported on high-risk medication use among older veterans with chronic pain. She said by email, "As clinicians we need to understand that not all of the outcomes we measure and not all of the medical conditions a patient has will be perceived as equally important (by the patient), so involving patients in the decision of which medications (even if guideline concordant) to add or remove is integral. How we communicate with and educate our older patients about their chronic conditions and the risks/benefits of each medication is evolving; this often differs between specialty providers and primary care providers."
Dr. Makris added, "This publication should heighten our awareness that patients, especially older adults, often have multiple comorbidities that can be treated with multiple guideline driven therapies and that our goal is really to work with patients to determine which combination of drugs and for which condition optimizes the risks/benefits for that individual."