Cardiovascular outcomes and fracture risk after the discontinuation of preventative medications in older patients with complex health needs: a self-controlled case series analysis

Objective To assess the effect of stopping statins, antihypertensives, and bisphosphonates on the risk of cardiovascular events and fractures in older patients with complex health needs (CHN). Methods Patients aged >65 years, registered in CPRD GOLD for ≥1 year before study start (01/01/2010) and with CHN (non-elective hospitalisation/s, frailty or polypharmacy) were selected. Self-controlled case series (SCCS) analyses were subsequently conducted among people who did not use the respective preventative treatment in the year before study start. Incidence rate ratios (IRR) were calculated for myocardial infarction (MI) and stroke [antihypertensives, statins] and fractures [bisphosphonates] comparing event rates for the respective outcomes during treatment vs. post-discontinuation periods. Results 198,039 people were included to the CHN cohort. Among those, 6,245 individuals were included for the analysis of bisphosphonate discontinuation and fracture risk; 738 and 669 persons for the analysis of antihypertensive therapy discontinuation and MI/stroke risk; and 1,408 and 1,361 people for statin discontinuation and MI/stroke risk. Risk of MI was substantially increased following discontinuation of antihypertensives (IRR 2.6 [95%CI 1.56-4.33]) and statins (IRR 1.75 [1.16-2.62]). No significant association for treatment discontinuation and stroke risk was seen. Likewise, no increased fracture risk was seen after discontinuing bisphosphonates. However, discontinuation among people with >1 year history of bisphosphonate therapy pointed towards increased fracture risk. Conclusions Our study showed risks associated with discontinuing preventative medications in people with CHN, likely explained by the continued efficacy of these medications. Further research focussing on the risk-benefit of these treatments for most vulnerable older adults is needed. Key points Self-controlled case series showed substantially increased risk for myocardial infarction following discontinuation of antihypertensives and statins. Fracture risk was not increased during treatment with bisphosphonates vs. post-discontinuation, but in people with >1 year of treatment a trend towards increased risk was seen. Future research is required to study further conditions, medications, and sequalae in older patients with complex health needs.