Recommendations for (Discontinuation of) Statin Treatment in Older Adults

Review of Guidelines

Milly A. van der Ploeg, MD; Carmen Floriani, MD; Wilco P. Achterberg, PhD; Jonathan M.K. Bogaerts, MD; Jacobijn Gussekloo, PhD; Simon P. Mooijaart, PhD; Sven Streit, PhD; Rosalinde K.E. Poortvliet, PhD; Yvonne M. Drewes, PhD

Disclosures

J Am Geriatr Soc. 2020;68(2):417-425. 

In This Article

Abstract and Introduction

Abstract

Objectives: As a person's age increases and his/her health status declines, new challenges arise that may lead physicians to consider deprescribing statins. We aimed to provide insight into recommendations available in international cardiovascular disease prevention guidelines regarding discontinuation of statin treatment applicable to older adults.

Design: We systematically searched PubMed, EMBASE, EMCARE, and the websites of guideline development organizations and online guideline repositories for cardiovascular disease prevention guidelines aimed at the general population. We selected all guidelines with recommendations (instructions and suggestions) on discontinuation of statin treatment applicable to older adults, published between January 2009 and April 2019. In addition, we performed a synthesis of information from all other recommendations for older adults regarding statin treatment. Methodological quality of the included guidelines was appraised using the appraisal of guidelines for research & evaluation II (AGREE II) instrument.

Results: Eighteen international guidelines for cardiovascular disease prevention in the general adult population provided recommendations for statin discontinuation that were applicable to older adults. We identified three groups of instructions for statin discontinuation related to statin intolerance, and none was specifically aimed at older adults. Three guidelines also included suggestions to consider statin discontinuation in patients with poor health status. Of the 18 guidelines included, 16 made recommendations regarding statin treatment in older adults, although details on how to implement these recommendations in practice were not provided.

Conclusion: Current international cardiovascular disease prevention guidelines provide little specific guidance for physicians who are considering statin discontinuation in older adults in the context of declining health status and short life expectancy.

Introduction

Up to the age of approximately 75 years, the effectiveness of cardiovascular preventive medication is undisputed and, together with lifestyle interventions, significantly reduces the impact of cardiovascular disease.[1–3] Also, for vital adults aged 75 to 85 years, there is evidence that the benefits of statins generally outweigh the risks, especially in secondary prevention.[4,5] However, when confronted with declining health status and the development of complex health problems, the use of preventive medications with long-term effects might become of questionable benefit; on the one hand, treatment priorities shift and life expectancy shortens, while on the other hand, the risks of adverse effects increase due to pharmacokinetic and pharmacodynamic changes, polypharmacy, and multimorbidity,[6–9] especially in old age. These risks can be influenced positively by decreasing medication prescriptions. In addition, high-quality evidence is not yet available for either primary or secondary statin-based prevention in people aged 85 years and older or in those with complex health problems (as they are currently excluded from trials).[10] In a recent meta-analysis of the efficacy and safety of statins for primary cardiovascular disease prevention in older adults, which included data from 28 trials, only 8% of all patients were aged older than 75 years at enrollment.[5] As statins are one of the most commonly used drugs in the older population, with a prevalence ranging between 18% and 45%,[11,12] with concerns about the benefits, they have been identified as possible candidates for deprescribing (the process of tapering or stopping inappropriate medication) by both clinicians and patients.[10,11,13–19] In a modified Delphi approach, physicians, pharmacists, and nurses prioritized statins in the top three of a list of medication classes where evidence-based deprescribing guidelines would be of benefit to clinicians because of concerns about benefit given the lack of older patients in trials, the lack of clarity around ongoing indication and when they can be stopped, as well as an emerging recognition of adverse effects and overtreatment of low-risk patients.[14]

Qualitative studies have shown that both physicians and patients are generally open to statin deprescription in the case of older adults.[19–22] Nevertheless, medications, including statins, are often continued until death.[17,23] It has been reported that physicians do not feel confident about deprescribing cardiovascular preventive medication and survey studies have found considerable treatment variation in the advice regarding discontinuation of preventive medication.[22,24,25] A likely contributing factor and an acknowledged barrier to deprescribing medications is the lack of evidence and clear guidance in clinical practice guidelines.[10,21,25] Therefore, the primary objective of this systematic review was to provide insight into the available recommendations regarding statin treatment discontinuation in older adults as provided by international guidelines on cardiovascular disease prevention in the general population. To explore the context of recommendations for discontinuation applicable to older adults, we additionally analyzed which other recommendations were formulated concerning statin treatment in older adults.

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