Perindopril starting dose errors in older adults in the Netherlands A retrospective, cross-sectional, population-based study

Abstract

BACKGROUND: To abate the risk of adverse drug events and improve therapy compliance in older patients, the Dutch general practitioners’ community introduced the “start-low-go-slow”- principle for older adults in the Cardiovascular Risk Management guidelines in 2011. This advice implies that older patients should start an antihypertensive drug at the lowest available dose. It is unknown whether healthcare providers adhere to these guidelines and whether older patients genuinely start with the lowest dose in clinical practice. We aimed to investigate the difference between in-clinical practice prescribed and guideline recommended starting doses in older adults, using the antihypertensive drug perindopril as a proof of concept.

METHODS: We conducted a retrospective, cross-sectional, population-based study, using data from the Rotterdam Study. All patients aged 70 years and older with a recorded first perindopril prescription in the database between January 1, 1991, and February 8, 2021, were included. The mean starting dose (MSD) was calculated and compared to the guideline recommendation of 2 mg perindopril, using a one-sample t-test. A sub analysis was done to analyze the MSDs before and after 2011.

RESULTS: There were 1019 eligible patients. The overall mean starting dose of perindopril was 3.34 mg (SD ± 1.623 mg). The mean starting dose prescribed to older adults in clinical practice was significantly higher than the recommended 2 mg perindopril. The MSD between 1991 and 2010 was 3.44 mg (SD ± 1.506 mg). Between 2011 and 2020 a MSD of 3.23 mg (SD ± 1.749 mg) was found. Both mean starting doses differed significantly from the guideline recommendations. A significant difference in MSDs pre- and post-2011 was found as well (p = 0.0397).

CONCLUSION: A small decrease in mean starting dose of perindopril in older adults has occurred after the introduction of the start-low-go-slow-principle in 2011. However, healthcare providers do not adhere to the guidelines as they still prescribe higher starting doses of perindopril in older patients than recommended by the national cardiovascular risk management guidelines. More research should be conducted to find out whether this is justified.