Risks associated with continuation of potentially inappropriate antihypertensive medications in older adults receiving hemodialysis

Rasheeda K. Hall, Sarah Morton, Jonathan Wilson, Patti L. Ephraim, L. Ebony Boulware, Wendy L. St. Peter, Cathleen Colón-Emeric, Jane Pendergast, Julia J. Scialla

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Background and objectives: After dialysis initiation, older adults may experience orthostatic or post-dialysis hypotension. Some orthostasis-causing antihypertensives (i.e., central alpha agonists and alpha blockers), are considered potentially inappropriate medications (PIMs) for older adults because they carry more risk than benefit. We sought to (1) describe antihypertensive PIM prescribing patterns before and after dialysis initiation and (2) ascertain the potential risk of adverse outcomes when these medications are continued after dialysis initiation. Design, setting, participants, and measurements: Using United States Renal Data System data, we evaluated monthly prevalence of antihypertensive PIM claims in the period before and after dialysis initiation among older adults aged ≥66 years initiating in-center hemodialysis in the US between 2013 and 2014. Patients with an antihypertensive PIM prescription at hemodialysis initiation and who survived for 120 days were classified as ‘continuers’ or ‘discontinuers’ based on presence or absence of a refill within the 120 days after initiation. We compared rates of hospitalization and risk of death across these groups from day 121 through 24 months after dialysis initiation. Results: Our study included 30,760 total patients, of whom 5981 (19%) patients had an antihypertensive PIM claim at dialysis initiation and survived ≥120 days. Most [65% (n = 3920)] were continuers. Those who continued (versus discontinued) were more likely to be black race (26% versus 21%), have dual Medicare-Medicaid coverage (31% versus 27%), have more medications on average (12 versus 9) and have no functional limitations (84% versus 80%). Continuers experienced fewer all-cause hospitalizations and deaths, but neither were statistically significant after adjustment (Hospitalization: RR 0.93, 95% CI 0.86, 1.00; Death: HR 0.89, 95% CI: 0.78–1.02). Conclusions: Nearly one in five older adults had an antihypertensive PIM at dialysis initiation. Among those who survived ≥120 days, continuation of an antihypertensive PIM was not associated with increased risk of all-cause hospitalization or mortality.

Original languageEnglish (US)
Article number232
JournalBMC Nephrology
Issue number1
StatePublished - Dec 2021

Bibliographical note

Funding Information:
Research reported in this publication was supported by the National Center for Advancing Translational Sciences under Award Number UL1TR002553, National Institute on Aging under Award Numbers P30AG028716, K76AG059930, and National Institute of Diabetes and Digestive and Kidney Diseases R01DK111952 of the National Institutes of Health. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. This research is also supported by the American Society of Nephrology and the Doris Duke Charitable Foundation. The findings and interpretation do not necessarily represent the official views of these foundations.

Publisher Copyright:
© 2021, The Author(s).


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