Individual research recommendation details

Recommendation ID

NG56/3

Question

Stopping preventive medicines:- What is the clinical and cost effectiveness of stopping preventive medicines in people with multimorbidity who may not benefit from continuing them?

Any explanatory notes
(if applicable)

Why this is important:- There is good evidence from randomised controlled trials of the medium term (2–10 years) benefit of medicines recommended in guidelines for preventing future morbidity or mortality, including treatments for hypertension, hyperglycaemia and osteoporosis. However, there is much less evidence about the balance of benefit and harm over longer periods of treatment. It is plausible that harms outweigh benefits in some people with multimorbidity (for example, because of higher rates of adverse events in older, frailer people prescribed multiple regular medicines, or because the expected benefit from continuing a preventive medicine is reduced when there is limited life expectancy or high risk of death from other morbidities). These people are unlikely to have been eligible or included in published trials showing initial benefit from preventive medicines. The systematic review undertaken by NICE in 2015 did not find any randomised controlled trials of stopping antihypertensive medicines in people with multimorbidity. The review found 1 small randomised controlled trial of stopping statins in people with a life expectancy of 1 year, but the committee did not consider this provided enough evidence to make a recommendation. The review found several randomised controlled trials of stopping bisphosphonates (although not clearly in populations with multimorbidity) and a recommendation was made for this, but no randomised controlled trials were found of stopping calcium and/or vitamin D. Recommendations based on robust evidence on the clinical and cost effectiveness of stopping preventive medicines in people with multimorbidity who may not benefit could have significant budgetary implications for the NHS. No ongoing trials have been identified.
The guideline committee considered that 1 or more large, well-designed trials of stopping preventive medicine in people with multimorbidity would be of value in defined patient groups in the community (for example, people in nursing homes, people who are housebound, people with well-defined frailty, people with high levels of multimorbidity or polypharmacy, people with limited life expectancy). Discontinuation could either be complete (all relevant medicines) or partial (for example, reduced intensity of hypotensive or hypoglycaemic treatment). Such trials have to be sufficiently powered to provide evidence of clinically important effects of interventions on outcomes that are relevant to patients and health and social care systems (for example, quality of life, hospital and care home admission and mortality). The committee believed that given the existing evidence, it would be of greater value to evaluate the effects of stopping discrete medicines or drug classes, rather than stopping all preventive medicines at the same time. The committee also believed that no single trial could likely address this research need, since there are many medicines that could be stopped and many defined populations in which this might be of value.

Source guidance details

Comes from guidance

Multimorbidity: clinical assessment and management

Number

NG56

Date issued

September 2016

Other details