Efficacy and safety of antihypertensive drugs deprescribing in older adults: A systematic review and meta-analysis of randomized controlled trials

Background: Although antihypertensive therapy is beneficial, aggressive treatment in frail, multimorbid older adults may increase adverse outcomes such as falls and hypotension. Deprescribing has emerged as a potential strategy to reduce these risks, but evidence regarding its safety remains limited. This systematic review and meta-analysis assessed the clinical outcomes of antihypertensive deprescribing in older adults. Methods: PubMed, Scopus, CENTRAL, and Web of Science were searched for randomized controlled trials (RCTs) published up to October 2025 comparing antihypertensive deprescribing with usual care. Primary outcomes were all-cause mortality, cardiovascular mortality, and all-cause hospitalizations. Secondary outcomes included major adverse cardiovascular events (MACE), serious adverse events (SAEs), and falls. Pooled risk ratios (RRs) were calculated using a random-effects model. Results: Four RCTs involving 2173 participants were included. Deprescribing showed no significant difference versus usual care in all-cause mortality (RR 1.02, 95 % CI 0.93-1.12), cardiovascular mortality (RR 1.11, 95 % CI 0.80-1.55), or all-cause hospitalizations (RR 0.95, 95 % CI 0.85-1.05). No significant differences were observed for MACE (RR 1.09, 95 % CI 0.90-1.33), MI (RR 0.76, 95 % CI 0.42-1.38), stroke (RR 1.12, 95 % CI 0.66-1.89), SAEs (RR 1.08, 95 % CI 0.90-1.30), or falls (RR 1.00, 95 % CI 0.89-1.13). Conclusion: In older adults, a strategy of deprescribing antihypertensive drugs was not associated with an increased risk of mortality, MACE, or other SAEs. Despite that these findings provide reassuring evidence for deprescribing strategies, the current evidence base remains limited and uncertain, warranting caution and strict clinical monitoring.