06.18.2025

Approach to Blood Pressure Lowering Agents in Hospice Care

For patients with limited life expectancy, hospice goals are focused on relief of suffering through pain and symptom management rather than disease prevention, life prolongation or treating diseases. Deprescribing, the systematic process of patient-specific medication assessment for benefit and tapering, withdrawing, or discontinuing medications as necessary, is recommended at end-of-life. Deprescribing reduces medication burden and the potential for adverse effects and drug interactions, improving patient safety and quality of life.1

Despite well-established best practices favoring deprescribing, clinicians are sometimes reluctant to deprescribe  cardiovascular (CV) medications due to a perception that they continue to benefit the patient, including medication classes that provide no short-term symptom relief and offer only long-term benefits (e.g., lipid-lowering agents, anti-platelet therapy).2  While several CV medication classes do palliate symptoms (Table 1) and  may be appropriate to continue at end-of-life, regular reassessment for deprescribing is still necessary, especially for medications that lower blood pressure.

Recognizing that stringent blood pressure goals coupled with CV changes in life-limiting illness may place patients at risk for falls due to hypotension, this article focuses on identifying and managing CV medications that lower blood pressure.

IDENTIFY BLOOD PRESSURE LOWERING AGENTS & CONDITIONS

In the context of end-of-life care, all medications that lower blood pressure should be identified and assessed for risk and benefit. These medications include agents indicated as primary (Table 2) or secondary antihypertensives (Table 3), other CV agents (Table 4) and non-CV medications with potential for hypotensive adverse effects (Table 5). Several diseases and conditions are also associated with hypotension (Table 6).3

The antihypertensive tables below list single medication agents only and are not comprehensive of all products. A variety of antihypertensive combination products are currently available on the market as well (e.g., lisinopril-hydrochlorothiazide (Zestoretic®)).

ADJUST THE BLOOD PRESSURE TARGET

After antihypertensive therapy is initiated, the blood pressure (BP) measurement target is typically < 130/80 in the non-hospice population and for adults younger than 65 years. Careful consideration is recommended when choosing a blood pressure target in older adults with hypertension and a high burden of comorbidity and limited life expectancy.3

The goal of blood pressure lowering in patients with hypertension is to reduce the risk for development of cardiovascular (CV) and cerebrovascular diseases, including stroke, coronary artery disease, heart failure, atrial fibrillation, abdominal aortic aneurysm, and peripheral vascular disease, especially among patients with multiple CV risk factors: 3,8,9

  • Modifiable CV risk factors – cigarette smoking, diabetes mellitus, elevated lipids, obesity, unhealthy diet
  • Fixed CV risk factors – chronic kidney disease, family history, age ≥ 65 years, obstructive sleep apnea

However, this must be weighed against the risk of causing hypotension, which is associated with increased risk of dizziness, lethargy, blurry vision, and falls. Shared decision making regarding reducing antihypertensive doses or cessation of therapy may be beneficial in the following groups:10

  • Frail elderly and/or immobile patients
  • Patients with a high fall risk
  • Patients with confirmed orthostatic hypotension ( > 20 mmHg drop in systolic blood pressure (SBP) and/or > 10 mmHg drop in diastolic blood pressure (DBP) upon standing)
  • Patients with limited life expectancy

ASSESS & REASSESS FOR DEPRESCRIBING OPPORTUNITIES

Simplifying a patient’s medication list and reducing the risk of adverse effects and drug interactions are benefits of deprescribing. Deprescribing blood pressure (BP) lowering therapy may be appropriate in the following scenarios:

  • BP is consistently below patient-specific target11-13
  • Patient is symptomatic of low blood pressure:4
    • Weakness
    • Dizziness
    • Lightheadedness
    • Blurred vision
    • Fatigue
    • Rapid heartbeat
    • Fainting, in severe cases
  • Medication is being used solely to address long-term cardiac risks (e.g., stroke, myocardial infarction)11-13
  • Any benefit(s) of the BP lowering therapy is/are not offset by the adverse effect(s) (Table 7):4,5,11-13

A concept in support of deprescribing antihypertensives is the “legacy effect”. It refers to clinical trial findings of long-term benefits of intensive therapy that persist after discontinuation in chronic diseases such as diabetes, hyperlipidemia, and hypertension.14 Most studies focus on intensive treatment regimens, whose main goal is to achieve tight control of one or more CV risk factors.15 Several clinical trials have assessed legacy effects in hypertensive patient populations after intensive BP control.16-22 This suggests that patients with a history of consistent BP control may continue to benefit from antihypertensive therapy even after it is discontinued.

There exist risks of discontinuing some antihypertensive medications that include rebound hypertension and withdrawal symptoms. Do not abruptly stop the below medications. Safe discontinuation requires slow tapering (e.g., halving the dose or, alternatively, reducing the dose by 25%, no more frequently than every 5 to 7 days) with close monitoring (Table 8):13,23-25

Other antihypertensives do not carry a risk of physiologic rebound and can be stopped without tapering. Follow-up is encouraged to evaluate patient response to medication withdrawal for all antihypertensive tapering or discontinuation.23

For additional guidance on prescribing palliative therapy and deprescribing in cardiovascular disease:

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References

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