{"id":858,"date":"2015-10-21T13:41:56","date_gmt":"2015-10-21T13:41:56","guid":{"rendered":"http:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/?p=858"},"modified":"2017-08-21T11:26:59","modified_gmt":"2017-08-21T11:26:59","slug":"primary-care-corner-with-geoffrey-modest-md-medication-in-elderly-with-comorbidities","status":"publish","type":"post","link":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2015\/10\/21\/primary-care-corner-with-geoffrey-modest-md-medication-in-elderly-with-comorbidities\/","title":{"rendered":"Primary Care Corner with Geoffrey Modest MD: Medication in Elderly with Comorbidities"},"content":{"rendered":"<p><strong>By Dr. Geoffrey Modest<\/strong><\/p>\n<p>BMJ printed a new\u00a0population-based cohort study looking at guideline-recommended drugs and deaths in older adults with multiple chronic conditions (see\u00a0BMJ 2015;351:h498). These guidelines were typically based on randomized control studies with younger people and a single chronic condition.<\/p>\n<p>Details:<\/p>\n<ul>\n<li>8578 older adults (mean age 77\u00a0with 36% &gt;80yo, 59% women, 87% white), having multiple chronic conditions:\u00a0hypertension\u00a0(HTN)\u00a0\u00a092%, hyperlipidemia (HL)\u00a077%\u00a0, diabetes (DM)\u00a040%\u00a0, coronary artery disease (CAD)\u00a039%, depression (DEP)\u00a026%, heart failure (HF)\u00a020%,\u00a0atrial fibrillation (AF)\u00a019%, chronic kidney disease (CKD)\u00a012%, and thromboembolic disease\u00a06%.<\/li>\n<li>Data were\u00a0from Medicare Current Beneficiary Survey cohort, a nationally representative\u00a0sample of Americans &gt;65yo, followed through 2011<\/li>\n<li>The 9 study drugs: RAS blockers (ACE-I or ARBs) were used in 54%, statins in 53%, thiazides 47%, b-blockers 47%, calcium channel blockers (not differentiated by class) in 33%, SSRIs\/SNRIs\u00a021%,\u00a0warfarin 14% , metformin 14%, clopidogrel 13%. 54% took at least 3 of the 9 study drugs. Mean total number of drugs (including nonstudy drugs) was\u00a010. They also\u00a0tracked changes in meds over the\u00a0study period<\/li>\n<li>Median follow-up of 24 months. 15% (1287) people died during follow-up.<\/li>\n<\/ul>\n<p>Results:<\/p>\n<ul>\n<li>Mortality over the 24 months: 27% in those with AF, 19% with CAD, 17% with DM, 33% with HF, 11% with HL, 15% with HTN<\/li>\n<li>For the specific drugs (all of below were\u00a0statistically significant), the HR for mortality was:\n<ul>\n<li>\u200bb-blockers: adjusted HR of 0.59 for AF, 0.70 for CAD,\u00a0 0.68 for HF, and 0.48 for combo of AF\/CAD\/HL\/HTN,\u00a00.59 for HF\/CAD\/HL\/HTN [note: an HR of 0.59 means a 41% decrease in mortality]<\/li>\n<li>Statins: \u00a0HR 0.75\u00a0for CAD, 0.75\u00a0for DM, 0.68 for HL, and 0.65 for combo DM\/CAD\/HL\/HTN, 0.68 for HF\/CAD\/HL\/HTN, 0.70 for DEP\/CAD\/HL\/HTN<\/li>\n<li>Calc channel blockers: HR 0.78 for AF, 0.85 for HTN, and 0.69 for DM\/CAD\/HL\/HTN, 0.71 for AF\/CAD\/HL\/HTN and 0.72 for HF\/CAD\/HL\/HTN<\/li>\n<li>Thiazides: no significant benefits for HTN or any of the combo comorbidities<\/li>\n<li>RAS blockers: 0.72 for HF, 0.80 for HTN, 0.82 for CAD, and 0.73 for AF\/CAD\/HL\/HTN, 0.77 for HF\/CAD\/HL\/HTN<\/li>\n<li>Clopidogrel: no significant benefit for AF or CAD, or any of the combos (aspirin use could not be tracked in this database)<\/li>\n<li>SSRI\/SNRI: no significant benefit for DEP or any of the combos<\/li>\n<li>Metformin: no significant benefit for DM or any of the combos<\/li>\n<li>Warfarin: 0.69 for AF, 0.44 for thromboembolic dz, but no benefit for any of the combos\u200b<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p>So, this study, I think, is important for several reasons:<\/p>\n<ul>\n<li>It largely reinforces what we are already doing, treating older\u00a0patients with comorbidities based on the usual randomized controlled trials which typically limited the age range to younger patients and those usually limited to a single disease (e.g., excluding those with renal failure, etc.). And, of course, as people get older, they regularly and routinely develop multiple comorbid conditions<\/li>\n<li>The study shows that in patients with multiple common comorbidities, the usual medications do improve mortality, even in a pretty short-term 2-year study. And the association between\u00a0drug use and mortality was pretty similar across patterns of coexisting comorbidities, suggesting that similar benefits were evident despite the presence of\u00a0comorbidities. This last finding supports the utility of randomized control trials limited to a single disease and then being\u00a0applied more generally, at least in the above diseases\/medications.\u200b\u200b<\/li>\n<li>Although there is empirical evidence that observational studies usually have similar results to controlled intervention studies (see Cochrane Database Syst Rev 2014;4:MR000034), one has to remain somewhat skeptical that there could be unexpected biases. This study was quite good in that it incorporated\u00a0certain social comorbidities (e.g. functional level, amount of time in the hospital, and living in a nursing facility), but still is open to the potential for other potential biases<\/li>\n<li>For example, it is pretty clear that many of the cardiac meds do well. The hardest one for me to accept is that metformin does not have clear benefit, though on each analysis, there was a clear non-significant trend to benefit. My guess is that there is a strong selection bias here: those who are sicker do not get metformin. My bet is that they have a little (or lot) of renal dysfunction, or heart failure, etc., which scare the providers away from using metformin, leaving only the healthier elderly on it (and with a\u00a0lower likelihood of showing mortality benefit in the healthier subgroup over a short 2-year study). \u00a0[Though, there are strong arguments that metformin is still a safe drug in many of these cases, esp. at a lower dose: See\u00a0<a href=\"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2015\/01\/23\/primary-care-corner-with-geoffrey-modest-md-metformin-in-renal-failure\/\">https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2015\/01\/23\/primary-care-corner-with-geoffrey-modest-md-metformin-in-renal-failure\/<\/a>]<\/li>\n<li>There have been\u00a0increasing studies showing that, for example, anticoagulation for the very common condition of atrial fibrillation\u00a0seems to be safer in the elderly than we thought in the old days, and I do have several patients into their late 80&#8217;s\/early 90&#8217;s doing very well\u00a0on them. And we know that the benefits of statins are typically evident within 6 months of starting them (based on studies of mostly younger people but some elderly) \u2013 i.e., these drugs seem to work well and are pretty well tolerated in the elderly.<\/li>\n<li>So, bottom line, this study provides some pretty strong\u00a0scientific rationale for continuing to treat elderly patients with their common multiple medical conditions with the same meds we have been using based on studies of younger people with single diseases.\u00a0\u200bBut, it is also important to bear in mind that this study only looked at\u00a0mortality, which is not the only important end-point&#8230;.<\/li>\n<\/ul>\n","protected":false},"excerpt":{"rendered":"<p>Primary Care Corner with Geoffrey Modest MD: Medication in Elderly with Comorbidities  [&#8230;]<\/p>\n<p><a class=\"btn btn-secondary understrap-read-more-link\" href=\"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2015\/10\/21\/primary-care-corner-with-geoffrey-modest-md-medication-in-elderly-with-comorbidities\/\">Read More&#8230;<\/a><\/p>\n","protected":false},"author":148,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_jetpack_memberships_contains_paid_content":false,"footnotes":""},"categories":[14283],"tags":[],"class_list":["post-858","post","type-post","status-publish","format-standard","hentry","category-archive"],"jetpack_featured_media_url":"","jetpack_sharing_enabled":true,"_links":{"self":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/posts\/858","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/users\/148"}],"replies":[{"embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/comments?post=858"}],"version-history":[{"count":0,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/posts\/858\/revisions"}],"wp:attachment":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/media?parent=858"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/categories?post=858"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/tags?post=858"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}