Statin Deprescribing Follow-up: How You Voted

Charles P. Vega, MD


February 26, 2019

Earlier this year, I posted a case, drawn from my practice, about an older adult who came to my practice already taking a statin. Because there are no clear guidelines to assist us in a decision about whether to maintain or discontinue statins in older adults who do not have a history of a previous major adverse cardiac event, I asked for advice from Medscape's readers. The huge response to the case was gratifying, and it reinforced that I was not alone in facing this type of scenario.

I concluded that I'd check a lipid panel and then reevaluate, and about two thirds of you agreed with me. A solid 1 out of 5 of you, however, argued for discontinuing the statin and presented valid reasons.

What did I learn from your questions, comments, and suggestions? First, a common theme voiced by a large number of readers centered on what I did not know about this man. Does he really have mild cognitive impairment? What is the status of his diabetes? And why, oh why, is he taking ASA and an NSAID?

These are critical issues, and readers picked up all of the holes in this case. No brief description can provide the detail you get when talking to a patient face to face. It was clear how thoroughly you examined the information provided and wanted to get it right. Obviously, there is no one correct answer here, but a few points can be addressed:

  • Absolutely, it's time to discontinue naproxen and take a hard look at whether aspirin will be beneficial. The risk for serious adverse events related to these drugs far outweighs his risk for complications due to a statin.

  • A very recently published meta-analysis found that statins were associated with a lower risk for vascular events and vascular mortality, regardless of age.[1] After exclusion of trials focused on adults with heart failure and receiving hemodialysis, there was no significant decline with age in the efficacy of statins for these outcomes.

  • A new scientific statement from the American Heart Association largely dismisses many safety concerns associated with statins.[2] It cites a risk for incident diabetes of 0.2% per year of statin use as well as a negligible, if any, impact on A1c values associated with statin use among adults with established diabetes. Moreover, it states that evidence from randomized controlled trials as well as systematic reviews has failed to find a definite link between statin use and cognitive dysfunction.

I appreciate the many voices of wisdom that urged looking beyond the lipid profile numbers, and even beyond this patient's cardiovascular risk profile, to establish the larger values and goals of the patient for his healthcare. Personally, I have at times become so focused on following an evidence-based guideline that I forget to get the patient's perspective on his own care. This is never a good practice, particularly with a case as controversial as this one.

Instead, we should start by establishing good rapport and trust with the patient and supporters. That might be the best medicine of all.

That said...

Have you ever had a patient refuse to stop antidepressant medications, even though they are probably not doing much good? Then stay tuned for the March 2019 edition of "Cases in Deprescribing."

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