12th August 2019, Dr Chee L Khoo
We are often reminded to review statins prescriptions for primary prevention in the “elderly” because the evidence of benefit of statins in this group of patients is often “lacking”. Lacking doesn’t mean it there is no benefit. It may mean there are no or limited studies done in that age group. Most clinical trials don’t include patients over 75 years old and as such, evidence is “lacking”. In primary care, the decision is not straight forward as one has to take into consideration many inter-related factors such as cost, potential side effects, meaningful life expectancy of the patient, presence or absence of other co-morbidities and safety of deprescribing. We need to look at both the safety and danger of deprescribing statins in the elderly patient.
In the PROSPER (Prospective Study of Pravastatin in the Elderly at Risk) trial pravastatin 40mg did not significantly reduce the incidence of coronary heart disease and stroke in patients aged 70–82 years on statins for primary prevention (1). However, the JUPITER (Justification for Use of Statins in Prevention: An Intervention Trial Evaluating Rosuvastatin) trial, found a significant reduction of cardiovascular events but not all-cause mortality in patients aged >70 years with no history of cardiovasculare disease (CVD) but had a high CRP low LDL-cholesterol levels (2). The meta-analysis by the Cholesterol Treatment Trialists’ Collaboration found that statins reduced vascular events irrespective of age, including in people older than 75 years although in the primary prevention setting, among people older than 75 years, there is less evidence of the effects of statin therapy (3). The evidence to continue statins or not can be conflicting.
In yet another study looking into whether existing statin therapy can be stopped in older people with no history of cardiovascular disease, Giral et al performed a retrospective cohort review derived from the French national health insurance claims database. All patients who turned 75 and had been taking a statin for at least 80% in each of the previous 2 years were eligible. Patients who already have a diagnosis of cardiovascular disease or taking at aspirin or other anti-platelet agent, combination of use of antiplatelet agent, b-blocker, and angiotensin-converting enzyme inhibitor (ACEI) or angiotensin II receptor blocker (ARB) were excluded. So, this is a pretty healthy cohort of patients.
A total of 120,773 patients were included in the study. The mean duration of follow up was 2.4 years (maximum 4 years). 17 204 patients discontinued statin therapy during follow up. The most common reasons for discontinuation were hospital or nursing home admission, initiation of oral feeds and diagnosis of metastatic solid tumours. Statins were usually discontinued when ACEI or ARBs were discontinued. Discontinuation of statins was associated with an increased risk of admission for a cardiovascular event (+33%). This association was stronger for admissions for coronary events than for admissions for cerebrovascular events (+46% and +26% increased risk, respectively).
The European guidelines on statin use for primary prevention in persons older than 75 years has no recommendations. At least , the 2018 American College of Cardiology/American Heart Association (ACC/AHA) guidelines recommend a “shared decision-making process between clinicians and these patients that targets individualized decisions, with regular reassessments over time” 10–12 . That isn’t much use to me in practice though.
Thus, the next time someone start stopping statins in your elderly patients, please initiate a conversation with the other doctor, the patient and the family. There are many factors to consider. More often than not, we know our patients better than the other doctor.
- Shepherd J, Blauw GJ, Murphy MB, et al. PROspective Study of Pravastatin in the Elderly at Risk. Pravastatin in elderly individuals at risk of vascular disease (PROSPER): a randomised controlled trial. Lancet 2002;360:1623–1630.
- Glynn RJ, Koenig W, Nordestgaard BG, Shepherd J, Ridker PM. Rosuvastatin for primary prevention in older persons with elevated C-reactive protein and low to average low-density lipoprotein cholesterol levels: exploratory analysis of a randomized trial. Ann Intern Med 2010; 152:488–496, W174.
- Cholesterol Treatment Trialists’ Collaboration. Efficacy and safety of statin therapy in older people: a meta-analysis of individual participant data from 28 randomised controlled trials. Lancet 2019;393:407–415.
- Giral P, Neumann A, Weill A, Coste J. Cardiovascular effect of discontinuing statins for primary prevention at the age of 75 years: a nationwide population-based cohort study in France. European Heart Journal (2019) 0, 1–10