Some thoughts on OPTIMISE trial just published in JAMA - RCT of deprescribing hypertension meds in adults age 80+ with SBP<150.

https://jamanetwork.com/journals/jama/fullarticle/2766421

@ParagGoyalMD @cardskrish @TimAndersonMD @AnilMakam @DeprescribeUS @Deprescribing @Reeve_Research

1/n

First, great to see rigorous RCT of deprescribing. Need more of this.

2/n

Appears that willingness to enroll in such trials continues to be a major challenge - of 6194 invited to attend, 4970 (80%) declined/did not respond, another 485 + 170 (11%) found ineligible. Curious to know how many ppl who declined were resistant to deprescribing.

3/n

34% of subjects in med reduction arm restarted treatment. Not a failure of intervention - that's the nature of therapeutic trials and reasonable that some ppl who stop meds need to have them restarted.

4/n

In an individual patient, can you tell if BP increased due to stopping meds? See graphs below from appendix. BP is highly variable visit to visit; if btwn visits, not necessarily due to med stoppage. Same principle applies widely, eg. with symptoms.

5/n

Increase in all-cause adverse events (49% vs 39%) in intervention vs control groups. Do not fully grasp adverse effect measures but suspect role of fear/attribution - if stop a med and then develop symptom, likely attribute it to the change rather than to other causes.

6/n

Is the mean increase in SBP of 3-4 mmHg an acceptable tradeoff for taking one fewer med? Probably depends on other risks, baseline BP, and prefs. SPRINT not a perfect answer but certainly argues for benefit of aggressive control even in old/multimorbid groups.

7/n

Trials like this highly needed but tradeoff of rigor vs. sample size & followup time. Not designed to evaluate long-term clinical outcomes. Pragmatic RCTs and well-done observational trials also needed to understand risks and benefits of deprescribing.

8/n

Finally, kudos to authorship team - well-done and important trial!

/end

@jamessheppard48 see some thoughts in this thread. Would love to hear your perspective. @DeprescribeUS