Safe prescribing of antihypertensive drugs in the elderly and managing the risk of adverse events

INTRODUCTION: Older patients with hypertension have unique clinical challenges based on age-related physiological changes, multimorbidity, and vulnerability to drug side effects. The 2017 American College of Cardiology/American Heart Association guidelines propose initiating antihypertensive therapy at a systolic blood pressure threshold of 130 mm Hg for non-institutionalized ambulatory adults over the age of 65. They also recommended individualized treatment for adults with advanced frailty or high risk of adverse events. AREAS COVERED: This article reviews evolving paradigms and strategies in blood pressure therapy in elderly individuals, based on shifting the approach from stringent treatment targets toward individualized management. Step-care management is one such strategy that involves prudent introduction of low doses of antihypertensives with regular follow-up to avoid side effects. Deprescribing is increasingly being promoted as a key intervention in reducing polypharmacy and maximizing safety in at-risk groups of patients. EXPERT OPINION: There is an increased need to incorporate frailty and functional assessments into routine practice and clinical trials. Despite growing evidence, there are still implementation challenges such as insufficient robust long-term data for frail populations. Pragmatic trials, adoption of digital solutions, and implementation of individualized goals must be the targets of future research.