Prescribing patterns in older people with advanced chronic kidney disease towards the end of life
Authors: Letts Matthew , Chesnaye Nicholas C , Pippias Maria , Caskey Fergus , Jager Kitty J , Dekker Friedo W , van Diepen Merel , Evans Marie , Torino Claudia , Vilasi Antonio , Szymczak Maciej , Drechsler Christiane , Wanner Christoph , Hole Barnaby , Hayward Samantha ,   the EQUAL study investigators, Schneider Andreas , Torp Anke , Iwig Beate , Perras Boris , Marx Christian , Drechsler Christiane , Blaser Christof , Wanner Christoph , Emde Claudia , Krieter Detlef , Fuchs Dunja , Irmler Ellen , Platen Eva , Schmidt-Gürtler Hans , Schlee Hendrik , Naujoks Holger , Schlee Ines , Cäsar Sabine , Beige Joachim , Röthele Jochen , Mazur Justyna , Hahn Kai , Blouin Katja , Neumeier Katrin , Anding-Rost Kirsten , Schramm Lothar , Hopf Monika , Wuttke Nadja , Frischmuth Nikolaus , Ichtiaris Pawlos , Kirste Petra , Schulz Petra , Aign Sabine , Biribauer Sandra , Manan Sherin , Röser Silke , Heidenreich Stefan , Palm Stephanie , Schwedler Susanne , Delrieux Sylke , Renker Sylvia , Schättel Sylvia , Stephan Theresa , Schmiedeke Thomas , Weinreich Thomas , Leimbach Til , Stövesand Torsten , Bahner Udo , Seeger Wolfgang , Cupisti Adamasco , Sagliocca Adelia , Ferraro Alberto , Mele Alessandra , Naticchia Alessandro , Còsaro Alex , Ranghino Andrea , Stucchi Andrea , Pignataro Angelo , De Blasio Antonella , Pani Antonello , Tsalouichos Aris , Antonio Bellasi , Iorio Biagio Raffaele Di , Alessandra Butti , Abaterusso Cataldo , Somma Chiara , D'alessandro Claudia , Torino Claudia , Zullo Claudia , Pozzi Claudio , Bergamo Daniela , Ciurlino Daniele , Motta Daria , Russo Domenico , Favaro Enrico , Vigotti Federica , Ansali Ferruccio , Conte Ferruccio , Cianciotta Francesca , Giacchino Francesca , Cappellaio Francesco , Pizzarelli Francesco , Greco Gaetano , Porto Gaetana , Bigatti Giada , Marinangeli Giancarlo , Cabiddu Gianfranca , Fumagalli Giordano , Caloro Giorgia , Piccoli Giorgina , Capasso Giovanbattista , Gambaro Giovanni , Tognarelli Giuliana , Bonforte Giuseppe , Conte Giuseppe , Toscano Giuseppe , Del Rosso Goffredo , Capizzi Irene , Baragetti Ivano , Oldrizzi Lamberto , Gesualdo Loreto , Biancone Luigi , Magnano Manuela , Ricardi Marco , Bari Maria Di , Laudato Maria , Sirico Maria Luisa , Ferraresi Martina , Provenzano Michele , Malaguti Moreno , Palmieri Nicola , Murrone Paola , Cirillo Pietro , Dattolo Pietro , Acampora Pina , Nigro Rita , Boero Roberto , Scarpioni Roberto , Sicoli Rosa , Malandra Rosella , Savoldi Silvana , Bertoli Silvio , Borrelli Silvio , Maxia Stefania , Maffei Stefano , Mangano Stefano , Cicchetti Teresa , Rappa Tiziana , Palazzo Valentina , De Simone Walter , Schrander Anita , van Dam Bastiaan , Siegert Carl , Gaillard Carlo , Beerenhout Charles , Verburgh Cornelis , Janmaat Cynthia , Hoogeveen Ellen , Hoorn Ewout , Dekker Friedo , Boots Johannes , Boom Henk , Eijgenraam Jan-Willem , Kooman Jeroen , Rotmans Joris , Jager Kitty , Vogt Liffert , Raasveld Maarten , Vervloet Marc , van Buren Marjolijn , van Diepen Merel , Chesnaye Nicholas , Leurs Paul , Voskamp Pauline , Blankestijn Peter , van Esch Sadie , Boorsma Siska , Berger Stefan , Konings Constantijn , Aydin Zeynep , Musiała Aleksandra , Szymczak Anna , Olczyk Ewelina , Augustyniak-Bartosik Hanna , Miśkowiec-Wiśniewska Ilona , Manitius Jacek , Pondel Joanna , Jędrzejak Kamila , Nowańska Katarzyna , Nowak Łukasz , Szymczak Maciej , Durlik Magdalena , Dorota Szyszkowska , Nieszporek Teresa , Heleniak Zbigniew , Jonsson Andreas , Blom Anna-Lena , Rogland Björn , Wallquist Carin , Vargas Denes , Dimény Emöke , Sundelin Fredrik , Uhlin Fredrik , Welander Gunilla , Hernandez Isabel Bascaran , Gröntoft Knut-Christian , Stendahl Maria , Svensson Maria , Evans Marie , Heimburger Olof , Kashioulis Pavlos , Melander Stefan , Almquist Tora , Jensen Ulrika , Woodman Alistair , McKeever Anna , Ullah Asad , McLaren Barbara , Harron Camille , Barrett Carla , O'Toole Charlotte , Summersgill Christina , Geddes Colin , Glowski Deborah , McGlynn Deborah , Sands Dympna , Caskey Fergus , Roy Geena , Hirst Gillian , King Hayley , McNally Helen , Masri-Senghor Houda , Murtagh Hugh , Rayner Hugh , Turner Jane , Wilcox Joanne , Berdeprado Jocelyn , Wong Jonathan , Banda Joyce , Jones Kirsteen , Haydock Lesley , Wilkinson Lily , Carmody Margaret , Weetman Maria , Joinson Martin , Dutton Mary , Matthews Michael , Morgan Neal , Bleakley Nina , Cockwell Paul , Roderick Paul , Mason Phil , Kalra Philip , Sajith Rincy , Chapman Sally , Navjee Santee , Crosbie Sarah , Brown Sharon , Tickle Sheila , Mathavakkannan Suresh , Kuan Ying 
Published: October 2024

ABSTRACT

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 m2. 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.