Stopping Statins Sits Well With Most Patients With Limited Life Expectancy

Patrice Wendling

June 13, 2017

WORCESTER, MA — A new survey suggests patients with advanced, life-limiting illnesses are more open than physicians might think to discontinuing statin therapy[1].

The study was published online recently in the Journal of Palliative Medicine.  

Of the 297 respondents, fewer than 5% agreed that stopping their statin meant their doctor "has given up on treating me" (3.4%) or "thinks I am about to die" (3%).

Instead, more participants agreed that statin discontinuation would carry potential benefits such as spending less money on medications (62.6%), stopping other drugs (34%), and having better quality of life (24.6%).

Perhaps tellingly, participants with cardiovascular disease as their primary life-limiting diagnosis were more likely to say they would have better quality-of-life off statins (39.1%) than those with cancer (23.4%) or other diagnoses (23.3%; P=0.034).

"We didn't know what we would find, but I certainly think there are practicing clinicians who will be surprised," lead author Dr Jennifer Tjia (University of Massachusetts Medical School, Worcester) said in an interview.

The issue of deprescribing is growing, given regulatory pressure to optimize medication use and some data that deprescribing may improve patient quality of life. But there is no single blueprint for end-of-life care, and many physicians fear their patients will feel abandoned.

"There is a lot of anecdote about what patients would feel if they start this conversation," said Tjia.

For cardiologists as a group, it can be difficult making that transition from aggressive care to a more comfort-type, palliative care and knowing when the appropriate time is to even broach the issue, particularly discontinuing statins, commented Dr Michael Rich (Washington University in St Louis), who was not involved with the study.

"There are data in the general population that stopping statins is associated with an increased risk for recurrent cardiovascular events and that's something that's ingrained in the culture of cardiology—that once someone is started on statins they should be on statins forever," he told heartwire from Medscape.

"That was something I found surprising, that only 13% [of CVD patients] said they were told they had to continue statins for the rest of their life. I think that might underestimate it. In reality, that proportion is higher."

The 297 patients who responded to the nine-question survey developed by an interdisciplinary team had a mean age of 72 years; 58% had cancer, 8% CVD, and 30% other primary diagnoses. They were part of the multicenter Statin Discontinuation in Advanced Illness trial[2] involving 381 cognitively intact patients, which reported that patients randomized to stop statin therapy had better total quality of life, used fewer nonstatin drugs, and saved an average of $716 less per patient than those continuing statins, without a significant increase in cardiovascular events.

Willingness to enroll in the parent trial suggests participants are at least open to the idea of stopping statins and is the primary limitation of the present analysis, senior author Dr Jon P Furuno, PhD (Oregon State University, Portland) acknowledged in an interview.

"That certainly does affect their perception, but it may just be the reality that people are in tune with their prognosis or see some benefits in stopping their medications," he added.

Some reports suggest that up to 90% of patients were willing to try discontinuation of their medications if their physician thought it appropriate.

In the present survey, 76.8% disagreed that "stopping statins would mean that all my previous efforts were wasted," while 17.5% agreed with the statement.

The geriatric cardiology section of the American College of Cardiology took up the issue of polypharmacy in the elderly in a workshop at ACC 2017, as part of its ongoing effort to integrate geriatric principles into the care of older adults with CVD.

"The specific goal of these meetings is to identify where the gaps are, what the needs are from the research perspective, and to formulate a research agenda to move the field forward," said Rich, who chaired the workshop.

He said there hasn't been a lot of research on deprescribing, and "there is certainly a great need for studies in the future" to address issues raised by this study such as quality of life and patient attitudes, but also physician attitudes, the risk of cardiac events, and survival when stopping statins in any population.

"What about those not necessarily approaching end of life but maybe are 83 or 85 years old and have multiple other medical problems and just plain don't want to take 15 or 20 medications, what about deprescribing statins in that population?"

The study was supported by the Palliative Care Research Cooperative Group funded by an award from the National Institute of Nursing Research. Tjia reports no relevant financial relationships. Furuno is a paid consultant and has received research funding and speaking honoraria from Merck. Disclosures for the coauthors are listed in the paper. Rich reported no relevant  financial relationships.

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