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

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.

Keywords: CKD; death; deprescriptions; elderly; polypharmacy.

Graphical Abstract

Figure 1:

Cohort flow diagram showing numbers of participants and prescribed medications.

Figure 2:

Total number of POMs over time leading up to death.

Figure 3:

Medication trajectories over the time leading up to death. Each graph shows the proportion of the population prescribed the named medication class over time. Yellow—targets for deprescribing; blue—medications for symptom control; grey—others prescribed to >25% of the cohort. NaHCO3–sodium bicarbonate. Supplementary data, Table S2 shows the included compounds in each of these medication classes.

Figure 4:

Trends of individuals’ prescribed medications comparing baseline study visits and final visits pre-death. NaHCO3–sodium bicarbonate. Supplementary data, Table S2 shows the included compounds in each of these medication classes.