Blood Pressure Lowering Drugs vs Hip Fracture

Unintended consequences.  As physicians, we always do our best to help our patients.  Certainly we strive to do no harm.  But sometimes, that's just not possible.  As I've noted previously, there's no free lunch so it often becomes a matter of choosing the lesser of two evils.  Until recently, just about everything that I'd read about high blood pressure was bad, which explains all our attempts to lower it.  But earlier this summer, a study was published in the Archives of Internal Medicine in which the authors concluded that robust old old benefited from antihypertensive therapy while the frail old old did not.

So I find it interesting that in a study published online earlier this week in the same Archives of Internal Medicine, the authors found that initiating use of blood pressure lowering medications increased the risk of hip fracture in community-dwelling elderly.  They followed 301,591 newly treated elderly, avg 81yo, and compared their risk for hip fracture for the 45 days immediately following the first prescription of an antihypertensive medication to the over 6 months before & after said initial prescription period.  

While use of any antihypertensive medication was statistically significantly linked to a 43% increase risk of hip fracture, this was mainly due to statistically significant increase risk from ACE inhibitors & beta blockers.  Thiaizide diuretics, ARBs and CCBs also increased risk of hip fracture but not in a statistically significant manner.

So how does this study impact our practice?  Do we stop prescribing medications?  Probably not.  Should our patients stop taking their medications?  Absolutely not!  How can  we safely get beyond the initial 45 days post-prescription?  It's unproven but I think we need to warn our patients to be very careful of position changes & orthostatic hypotension, especially if given ACE inhibitors and/or beta blockers.  Sure, the increased risk of a hip fracture is scary to ponder, but balance that against an increase risk of stroke & kidney failure if we don't treat high blood pressure.  Like I said, unintended consequences.  Risk, benefit & alternatives.  Communication is key.

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