What are the recommendations for deprescribing (discontinuing) anti-hypertensive medication in patients on hospice (palliative care) who are declining?

Deprescribing Antihypertensive Medications in Hospice and Palliative Care Patients

Antihypertensive medications should be deprescribed in declining hospice patients as they provide minimal benefit and may contribute to symptom burden through adverse effects like hypotension, falls, and fatigue.1

Assessment Framework for Deprescribing

When considering deprescribing antihypertensive medications in palliative care patients, follow this structured approach:

1. Identify candidates for deprescribing:

   • Patients with limited life expectancy (<6 months)
   • Patients experiencing functional decline
   • Patients with symptomatic hypotension (systolic BP <100 mmHg)
   • Patients with medication burden affecting quality of life

2. Prioritize medications for deprescription:

   • First tier (highest priority for deprescription):

     • Beta-blockers (unless treating heart failure symptoms)
     • Medications primarily for long-term prevention
     • Medications causing adverse symptoms (fatigue, dizziness)

   • Second tier:

     • ACE inhibitors/ARBs (unless treating heart failure symptoms)
     • Calcium channel blockers

   • Consider maintaining:

     • Loop diuretics if needed for symptom control of congestion
     • Medications that directly improve current symptoms

Evidence-Based Recommendations by Medication Class

Beta-Blockers

• Should be deprescribed in declining palliative care patients without other indications 1
• May contribute to fatigue and functional decline
• Require slow tapering to prevent rebound hypertension
• Can exacerbate symptoms in patients with low cardiac output

ACE Inhibitors/ARBs/Vasodilators

• Consider deprescribing when patients experience:
  • Symptomatic hypotension
  • Declining renal function
  • Orthostatic symptoms
• May still provide symptom benefit in heart failure by decreasing intracardiac filling pressures 1

Diuretics

• Loop diuretics often need to be continued or even escalated for symptom control of congestion
• Mineralocorticoid receptor antagonists may be continued for symptom relief with minimal blood pressure effects
• Consider deprescribing if causing electrolyte abnormalities or urinary frequency that impacts quality of life

Calcium Channel Blockers

• Consider deprescribing if causing symptomatic hypotension
• May be maintained if well-tolerated and controlling symptoms

Deprescribing Process

1. Review current blood pressure readings - Identify patients with SBP <120 mmHg who may be overtreated 2

2. Withdraw medications gradually:

   • Reduce one medication at a time at 4-week intervals 3
   • Start with medications least likely to cause withdrawal symptoms
   • Beta-blockers should be tapered slowly to prevent rebound effects

3. Monitor for adverse effects:

   • Check blood pressure after deprescribing
   • Monitor for symptom improvement or deterioration
   • Be alert for rebound hypertension with certain medications

Special Considerations

Heart Failure Patients

• Many heart failure medications provide symptom relief even at end of life
• Loop diuretics are frequently continued for symptom control
• Consider maintaining SGLT2 inhibitors if well-tolerated due to favorable side effect profile 1
• Beta-blockers may require de-escalation if causing fatigue or hypotension

Common Pitfalls to Avoid

1. Continuing preventive medications unnecessarily - Studies show 28.9% of patients continue antihypertensive treatment up to their last week of life 4

2. Inadequate monitoring - Over 50% of palliative care patients on antihypertensives don't have blood pressure monitored 4

3. Abrupt discontinuation - Particularly problematic with beta-blockers and clonidine which require tapering

4. Failing to consider medication burden - Each additional medication increases risk of drug interactions and reduces quality of life

5. Not involving patients in decision-making - Medication deprescribing should be aligned with patient goals of care 1

By systematically evaluating antihypertensive medications in declining hospice patients and deprescribing appropriately, clinicians can reduce medication burden and improve quality of life while maintaining symptom control.