#325 Prescribing patterns in older people with advanced chronic kidney disease approaching the end of life
Authors: Letts Matthew , Chesnaye Nicholas , Pippias Maria , Caskey Fergus , Jager Kitty J , Dekker Friedo W , Evans Marie , Torino Claudia , Szymczak Maciej , Wanner Christoph , Hole Barnaby , Hayward Samantha 
Published: May 2024

Abstract

Background and Aims
Advancing age and chronic kidney disease (CKD) are risk factors for polypharmacy—the regular daily intake of &gt;5 medications. Polypharmacy is a key action area for the World Health Organization in its effort to reduce global medication-related harm. Deprescribing, the systematic review and rationalisation of potentially inappropriate medications, is a proposed way of addressing polypharmacy. Deprescribing is particularly relevant near the end of life, when preventative treatments provide less benefit. Prescribing practices for elderly people with advanced CKD in the last years of life are currently unknown. The aim of this study was to describe prescribing and deprescribing patterns in such a cohort.

Method
The EQUAL study [1] is an international, prospective cohort study of people ≥65 years with an incident estimated glomerular filtration rate (eGFR) of ≤20 ml/min/1.73 m2. We analysed data from participants who died during follow up, including 3-6 monthly study-visit-collected prescribed oral medications (POMs). Generalized additive models were used to explore trends leading up to death in the total number of POMs, and the proportion of participants taking specific medications. Data are presented for medications: a) identified as targets for deprescribing in the elderly with CKD (statins, proton-pump inhibitors (PPIs) and antihypertensives—alpha-blockers, beta-blockers, calcium-channel blockers (CCBs), diuretics and renin-angiotensin-aldosterone inhibitors (RAASis)); b) used for symptom control in kidney failure (opioids and gabapentinoids); and c) prescribed to &gt;30% of the cohort (allopurinol, aspirin, vitamin D).

Results
Data from 563 participants were analysed, comprising 2793 study visits (median follow-up time 2.2 years (interquartile range (IQR) 1.1-3.8) pre-death), and 22,200 POMs. At baseline, mean age was 77.8 years (standard deviation (SD) 6.7), median eGFR 18.1 mls/min/1.73 m2 (IQR 15.0-21.2), and 87.2% were experiencing polypharmacy. The number of POMs increased over the time approaching death (Fig. 1)—7.3 (95% confidence interval (CI) 6.9-7.7) at 5 years pre-death, 8.3 (95% CI 8.0-8.6) at 2.5 years pre-death, and 8.7 (95% CI 8.4-9.1) at death. At their final study visit 90.1% were experiencing polypharmacy. Trends in the proportion of individuals prescribed specific medications differed by POM class (Fig. 2). Opioids, diuretics and PPIs increased in the last years of life; statins, RAASis, alpha-blockers and CCBs decreased; and allopurinol, beta-blockers and gabapentinoids remained stable. Aspirin and vitamin D showed phasic patterns, increasing then decreasing.

Conclusion
Elderly people with advanced CKD experience increasing levels of polypharmacy as they approach the end of life. Although there is evidence that certain medication classes are being deprescribed, this is outweighed by increased prescribing of other agents. Previous analyses of EQUAL decedents have shown that blood pressure decreases pre-death—we show this is despite reductions in most classes of antihypertensives. Our work suggests a high reliance upon pharmacological interventions (both symptom-directed and preventative) for older people with CKD who are approaching death. We cannot ascertain whether this reflects personalised prescribing, aligned with individuals’ preferences and prognoses; however, high levels of polypharmacy potentiate risks of side effects, medication burden and drug-drug interactions, and indicate a role for enhanced medication review in this setting.