Prescribing patterns in older people with advanced chronic kidney disease towards the end of life.

Background: Advancing age and chronic kidney disease (CKD) are risk factors for polypharmacy. Polypharmacy is associated with negative healthcare outcomes. Deprescribing, the systematic rationalization of potentially inappropriate medications, is a proposed way of addressing polypharmacy. The aim of this study was to describe longitudinal prescribing patterns of oral medications in a cohort of older people with advanced CKD in their last years of life.
Methods: The European QUALity (EQUAL) study is a European, prospective cohort study of people ≥65 years with an incident estimated glomerular filtration rate (eGFR) of ≤20 mL/min/1.73 m ² . We analysed a decedent subcohort, using generalized additive models to explore trends in the number and types of prescribed oral medications over the years preceding death.
Results: Data from 563 participants were analysed (comprising 2793 study visits) with a median follow-up time of 2.2 years (interquartile range 1.1-3.8) pre-death. Participants' numbers of prescribed oral medications increased steadily over the years approaching death-7.3 (95% confidence interval 6.9-7.7) 5 years pre-death and 8.7 (95% confidence interval 8.4-9.0) at death. Over the years pre-death, the proportion of people prescribed (i) proton-pump inhibitors and opiates increased and (ii) statins, calcium-channel blockers and renin-angiotensin-aldosterone system inhibitors decreased, whilst (iii) beta-blockers, diuretics and gabapentinoids remained stable. At their final visits pre-death 14.6% and 5.1% were prescribed opiates and gabapentinoids, respectively.
Conclusion: Elderly people with advanced CKD experienced persistent and increasing levels of polypharmacy as they approached the end of life. There was evidence of cessation of certain classes of medications, but at a population level this was outweighed by new prescriptions. This work highlights the potential for improved medication review in this setting to reduce the risks associated with polypharmacy. Future work should focus at the individual patient-clinician level to better understand the decision-making process underlying the observed prescribing patterns.
Competing Interests: F.C. reports grant funding from ERA and NIHR for conducting the EQUAL study. K.J.J. also reports grant funding from ERA to conduct the EQUAL study, and registry funding from the European Society of Paediatric Nephrology. M.E. reports payment for advisory boards, lectures by Fresenius Medical Care, Baxter Healthcare, Astellas Pharma, Vifor Pharma, Boehringer-Ingelheim and AstraZeneca, and institutional grants from AstraZeneca and Astellas Pharma. M.E. is also a member of the steering committee for the Swedish Renal Registry. C.W. had no conflict in respect to the present research. Outside this research, honoraria for consultancy and lecturing were received from Amgen, Amicus, AstraZeneca, Bayer, Boehringer-Ingelheim, Eli-Lilly, GSK, MSD, Novo Nordisk and Sanofi. All remaining authors declare no conflicts of interest.
(© The Author(s) 2024. Published by Oxford University Press on behalf of the ERA.)