Drug prescription before and after dialysis initiation in older patients: a nationwide study

Older patients on dialysis have a complex regimen of drugs to manage their chronic kidney disease (CKD), associated complications, and co-morbidities. Our aim was to describe drug use in the year before and after dialysis initiation in the older population. We included all patients aged ≥ 65 years initiating chronic dialysis in France between 2010 and 2019 identified from the national kidney replacement therapy registry and matched with the national health data system. Drug use prevalence was described by pharmacotherapeutic classes, based on anatomical therapeutic chemical codes, and estimated quarterly for patients with ≥ 1 drug dispensing in the year before and after the initiation of dialysis. Analysis was stratified according to dialysis modality, sex, and age at dialysis initiation. Among 55,238 patients included, hyper-polypharmacy (≥ 10 drugs) rose to 76% at dialysis initiation, and slightly decreasing afterwards. Non-CKD-related drugs, including insulins, psychotropic, analgesic and non-antihypertensive cardiovascular drugs, showed stable prevalence, except for proton pump inhibitors (PPI) use which rose sharply before dialysis (40.8% to 54.8%) and then stabilized. Conversely, CKD-related drugs varied. At dialysis initiation, antihypertensives (except diuretics), potassium binders, and hypouricemic agents use declined, while calcium supplementation rose then stabilized. Vitamin D and phosphate binder use increased steadily. Trends in drug use patterns were similar across dialysis modality, sex and age. Prescription changes occur at dialysis initiation, particularly for CKD-related drugs. Hyperpolypharmacy was highly prevalent, yet much of it is likely appropriate given the complex clinical profile of older dialysis patients. Further work is needed to explain the high prevalence of PPI. - This nationwide study of older French patients shows that dialysis initiation is accompanied by many changes mainly in CKD-related drugs and that hyper-polypharmacy remains high. - Proton pump inhibitor use rises sharply before dialysis and remains high afterwards. - Trends are consistent across dialysis modality, sex, and age groups. - These findings reinforce the need to support patients in their medication management, particularly at the time of dialysis initiation. - Further studies are needed to better understand the persistent hyper-polypharmacy and especially the increase in PPI use and to investigate the appropriate or inappropriate use of the drugs used.