Should a patient be weaned off of Blood Pressure (BP) medications?

Weaning Patients Off Blood Pressure Medications

Patients should not be weaned off blood pressure medications unless there is a specific clinical indication, as discontinuation can lead to worsening blood pressure control and increased cardiovascular risk. 1

When to Consider Medication Adjustment

Blood pressure medications should generally be continued long-term, but medication adjustment may be considered in specific situations:

1. Medication-induced hypertension:

   • When BP elevation is caused by substances that can be discontinued (NSAIDs, oral contraceptives, decongestants, etc.) 1
   • In these cases, the offending agent should be reduced or discontinued, and alternative agents used when feasible

2. Orthostatic hypotension:

   • For patients experiencing symptomatic orthostatic hypotension 1
   • Consider slower titration or lower dosing in these cases

3. Advanced age and frailty:

   • In patients aged ≥85 years or with moderate-to-severe frailty 1
   • These patients may benefit from less aggressive treatment approaches

Evidence-Based Approach to BP Medication Management

The European Society of Cardiology (2024) recommends:

• Maintaining BP control to reduce risk of stroke, heart failure, myocardial infarction, and cardiovascular death 1, 2
• Treating BP to target within 3 months to ensure long-term adherence and reduce cardiovascular risk 1
• Using combination therapy for most patients with confirmed hypertension (≥140/90 mmHg) 1

Risks of Discontinuing BP Medications

Abrupt discontinuation of antihypertensive medications can lead to:

• Rebound hypertension, particularly with beta-blockers and central alpha-2 agonists 2
• Increased risk of cardiovascular events 3
• Potential for hypertensive crisis (systolic BP >180 mmHg or diastolic BP >120 mmHg) 4

Improving Medication Adherence Instead of Discontinuation

Rather than discontinuing medications, focus on improving adherence:

• Fixed-dose single-pill combinations are strongly recommended (Class I, Level B) to improve adherence 1
• Consistent timing of medication taking improves adherence - medications should be taken at the most convenient time of day 1
• Electronic monitoring of compliance can help identify and solve problems with adherence 5, 6
• Long-acting medications that provide control beyond the 24-hour dosing period should be considered for patients with adherence challenges 7

Practical Considerations for Medication Management

• Medication timing: Recommend taking medications at the same time each day in a consistent setting to improve adherence 1
• Monitoring: Regular BP monitoring (both sitting and standing) to assess for orthostatic changes 2
• Laboratory assessment: Check renal function and electrolytes within 1-2 weeks of adding a new antihypertensive agent 2

Special Populations

• Elderly patients: Target BP for patients ≥65 years is 130-139/70-79 mmHg according to ESC/ESH, and <140/90 mmHg according to AHA 2
• Patients with resistant hypertension: A triple drug regimen of an ACE inhibitor/ARB, calcium channel blocker, and thiazide diuretic is recommended as foundation therapy 2

Remember that poor medication adherence is a major cause of unsatisfactory blood pressure control, with nearly 70% of patients not having their hypertension adequately controlled 5, 7. Therefore, efforts should focus on improving adherence rather than discontinuing effective therapy.