Iyer Shoba, Naganathan Vasi, McLachlan Andrew J, Le Couteur David G
Centre for Education and Research on Ageing, Concord RG Hospital and University of Sydney, Sydney, New South Wales, Australia.
Drugs Aging. 2008;25(12):1021-31. doi: 10.2165/0002512-200825120-00004.
The objective of this review was to assess the benefits and risks of medication withdrawal in older people as documented in published trials of medication withdrawal. This was done by systematic review of the evidence from clinical trials of withdrawal of specific classes of medications in patient populations with a mean age of >or=65 years. We identified all relevant articles published between 1966 and 2007 initially through electronic searches on PubMed and manual searches of review articles. Numerous search terms related to the withdrawal of medication in older people were utilized. Clinical trials identified were reviewed according to predetermined inclusion/exclusion criteria. Only trials that focused on the withdrawal of specific classes of medication were included. Thirty-one published studies (n = 8972 subjects) met the inclusion criteria, including four randomized and placebo-controlled studies (n = 448 subjects) of diuretic withdrawal, nine open-label and prospective observational studies (n = 7188 subjects) of withdrawal of antihypertensives (including diuretics), 16 studies (n = 1184 patients) of withdrawal of sedative, antidepressant, cholinesterase inhibitor and antipsychotic medications, and 1 study each of withdrawal of nitrates and digoxin. These studies were of heterogeneous study design, patient selection criteria and follow-up. Withdrawal of diuretics was maintained in 51-100% of subjects and was unsuccessful primarily when heart failure was present. Adverse effects from medication withdrawal were infrequently encountered. After withdrawal of antihypertensive therapy, many subjects (20-85%) remained normotensive or did not require reinstatement of therapy for between 6 months and 5 years, and there was no increase in mortality. Withdrawal of psychotropic medications was associated with a reduction in falls and improved cognition. In conclusion, there is some clinical trial evidence for the short-term effectiveness and/or lack of significant harm when medication withdrawal is undertaken for antihypertensive, benzodiazepine and psychotropic agents in older people.
本综述的目的是评估在已发表的撤药试验中所记录的老年人撤药的益处和风险。通过对平均年龄≥65岁的患者群体中特定类别药物撤药的临床试验证据进行系统评价来实现这一目的。我们最初通过在PubMed上进行电子检索以及对综述文章进行手工检索，找出了1966年至2007年间发表的所有相关文章。使用了许多与老年人撤药相关的检索词。根据预先确定的纳入/排除标准对所确定的临床试验进行了评价。仅纳入了关注特定类别药物撤药的试验。31项已发表的研究（n = 8972名受试者）符合纳入标准，包括4项利尿剂撤药的随机安慰剂对照研究（n = 448名受试者）、9项抗高血压药（包括利尿剂）撤药的开放标签前瞻性观察性研究（n = 7188名受试者）、16项镇静剂、抗抑郁药、胆碱酯酶抑制剂和抗精神病药物撤药的研究（n = 1184名患者），以及各1项硝酸盐和地高辛撤药的研究。这些研究在研究设计、患者选择标准和随访方面存在异质性。51%至100%的受试者维持了利尿剂撤药，主要在存在心力衰竭时撤药未成功。撤药的不良反应很少见。停用抗高血压治疗后，许多受试者（20%至85%）在6个月至5年期间血压保持正常或无需恢复治疗，且死亡率没有增加。停用精神药物与跌倒减少和认知改善相关。总之，有一些临床试验证据表明，老年人停用抗高血压药、苯二氮卓类药物和精神药物时具有短期有效性和/或无显著危害。
