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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
https://jamanetwork.com/journals/... href="https://twitter.com/ParagGoyalMD">@ParagGoyalMD @cardskrish @TimAndersonMD @AnilMakam @DeprescribeUS @Deprescribing @Reeve_Research
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https://jamanetwork.com/journals/jama/fullarticle/2766421
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@ParagGoyalMD @cardskrish @TimAndersonMD @AnilMakam @DeprescribeUS @Deprescribing @Reeve_Research 1/n" title="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/... href="https://twitter.com/ParagGoyalMD">@ParagGoyalMD @cardskrish @TimAndersonMD @AnilMakam @DeprescribeUS @Deprescribing @Reeve_Research 1/n" class="img-responsive" style="max-width:100%;"/>
First, great to see rigorous RCT of deprescribing. Need more of this.
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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.
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34% of subjects in med reduction arm restarted treatment. Not a failure of intervention - that& #39;s the nature of therapeutic trials and reasonable that some ppl who stop meds need to have them restarted.
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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 
https://abs.twimg.com/emoji/v2/... draggable="false" alt="⬆️" title="Upwards arrow" aria-label="Emoji: Upwards arrow"> btwn visits, not necessarily due to med stoppage. Same principle applies widely, eg. with symptoms.
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btwn visits, not necessarily due to med stoppage. Same principle applies widely, eg. with symptoms.5/n" title="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 https://abs.twimg.com/emoji/v2/... draggable="false" alt="⬆️" title="Upwards arrow" aria-label="Emoji: Upwards arrow"> btwn visits, not necessarily due to med stoppage. Same principle applies widely, eg. with symptoms.5/n" class="img-responsive" style="max-width:100%;"/>
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.
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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.
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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.
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Finally, kudos to authorship team - well-done and important trial!
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@jamessheppard48 see some thoughts in this thread. Would love to hear your perspective. @DeprescribeUS
