Should Elders Take Cholesterol-lowering Drugs (“statins”)

 

Should Elders Take Cholesterol-lowering Drugs (“statins”)

 

Background

Although there is research encouraging people to take drugs called “statins” (such as Crestor, Lipitor, Pravachol, Zocor) to lower their cholesterol and reduce the risk of a heart attack or stroke, how much benefit is there particularly for those over 75 years of age?

 

 

 

What’s the Evidence?

1.  Do these drugs lower cholesterol?  Yes.

Numerous studies demonstrate they reduce total blood cholesterol up to 20% (e.g. from 240 to 192) and bad cholesterol (LDL) up to 28% or more (e.g. from 150 to 108).

 

2.  But, do these drugs reduce heart attacks and deaths?  Yes and No.

Oxford University’s website Bandolier, reviews research worldwide to produce evidence-based summaries on various issues in healthcare.  Their most recent review (2004) concluded that overall there is some benefit to taking statins:   to prevent one person from having a heart attack, a stroke, or dying from heart disease, 19 must take a statin daily for five years (“19” is referred to as NNT or Number Needed to Treat.  The lower the NNT, the closer to “1”, the better.  For ‘prevention’ purposes, having a NNT of less than “20 – 40” is considered beneficial). However, since 2004, several reviews have concluded there is less benefit, if any at all, particularly for seniors.  For example [3],  for those over 65 years, the NNT to prevent one heart-related death in 5 years was 28: 18.8% of people died while not on a statin, compared to 15.6% dying while taking a statin (a 3.2% difference).  And, to prevent one heart attack, the NNT was 38. The British National Institute of Clinical Effectiveness (NICE) in 2008 recommended that patients with elevated lipids but without heart disease should take statins only if their 10-year risk of having a heart attack is greater than 20% (meaning 1 in 5 people will have a heart attack).  [to determine your personal risk, go to http:// hp2010.nhlbihin.net/atpiii/calculator.asp?usertype=prof]

 

3.  Do these drugs reduce your risk of having a stroke?  Not much.

The research suggests a lack of benefit:  Bandolier found a NNT of 101 to prevent one stroke (e.g. four in a 100 of those on a statin had a stroke compared to five in a 100 not taking the drug – only a 1% reduction); but, there has been no reduction in overall deaths.

 

4.  Are there significant side-effects from these drugs?   Several side-effects have been described, but tend to be minimized:  muscle aching (30%), paresthesias (pins/needles, numbness), confusion, and abnormal liver tests.  Many elders report an ‘achiness’ which disappears when they stop their statin.  Dr. Barbara Roberts has an excellent summary of the pros and cons about ‘statins’ [The Truth about Statins].

Perhaps this is why 50% of people stop taking the drugs within six months.  And, one study has found that low cholesterol in elders over 75years actually increases the risk of dying!

 

 

How do You Interpret the Evidence

 

There is no guarantee that these drugs will prevent heart disease, stroke, or death—they may only reduce the risk.  Therefore, each person must weigh the potential benefits against the risks.  It is difficult to estimate how much gain one person can expect based on studies involving thousands of people.  For some people, a 3.2% reduction in their risk is worth any cost or irritation.  A 3.2% benefit means that of 1000 people taking the drug, only 32 fewer than expected will have a heart attack or stroke or die (but, if you are one of the 32, that’s significant!). These drugs seem to benefit most those who:  1) are relatively healthier (meaning they don’t have a lot of other chronic illnesses) and under age 75;  2) have the highest cholesterol levels (over 240);  3) have risk factors for heart disease and/or have already had a heart attack.  But, elders who have a lot of other chronic diseases making them more frail or vulnerable to dying prematurely may not benefit as much.

 

What Should YOU do?

 

1.  First, identify your healthcare goals (see HealthCare Goals handout).

This is the most important consideration because it will help guide your decisions about any drug or treatment:  is your goal longevity, or comfort.  For example, if it is comfort only (do nothing which does not improve comfort and avoid anything which might increase pain/suffering), then these drugs may not be appropriate.

 

2.  Assess your current state of health.

If you are fairly healthy, independent in your daily activities, not taking a lot of medications already, and have a history of heart disease and elevated cholesterol, then – if changing your diet hasn’t helped – taking one of the “statins” may be appropriate, regardless of your age. Find out what the actual guidelines are for taking statins and if you meet them.  Know that exercise can decrease your total cholesterol 5% and a high fiber diet can drop it another 14%!

If you have a number of chronic ailments (diabetes, arthritis, heart failure, emphysema), and depend on others to help you for some daily activities, then you may not benefit from these drugs as much.  Residents of nursing homes are in this category.

For those with any dementia (for example, Alzheimer’s), because it is a terminal disease, preserving thinking ability as long as possible should be important – this means avoiding as many drugs as possible (especially any which could cause more confusion).

 

3.  Put the issue in proper perspective.

The average life expectancy for Americans is now 77 years.  Once you’ve reached that, some say every day is a gift.  Will taking pills give additional days of true comfort or be more of a nuisance and an unwelcome expense?  Is an elder entitled to “eat and do what I want” (within reason) once she reaches that age?  Which is more important to you:  the quality of the years lived or living more years?

Finally, elders are not simply “older adults”.  Because their bodies metabolize drugs differently, there are more side-effects.  Generally, elders feel better and look better if they take fewer pills.

If you are taking one of these drugs and aren’t sure what to do, stop taking your statin for a month and see how you feel; if you feel better, resume it and see if your symptoms recur.  Then, you be the judge.

Finally, reading Dr. Roberts book, The Truth About Statins, may provide additional perspective.

 

 

 

References:

Bandolier: evidence based healthcare.  Cholesterol & Statins. Oxford University April 2004.

Cooper A, O’Flynn N. Risk assessment and lipid modification for primary and secondary prevention of cardiovascular disease: summary of NICE guidance. BMJ 2008;336:1246-48.

Afilalo J, et al. Statins for secondary prevention in elderly patients. J Am Coll Cardiol 2008;51:37-45.

Strandberg TE. Multifactorial intervention to prevent recurrent cardiovascular events in patients 75 years or older. The Drugs & Evidence-Based Medicine in the Elderly (DEBATE) study: a randomized, controlled trial. Am Heart J 2006; 152:585-92.

Thavendiranathan P, et al. Primary prevention of cardiovascular disease with statin therapy. Arch Intern Med 2006;166:2307-13.

Briel M, et al. Effects of early treatment with statins on short-term clinical outcomes in acute coronary syndromes. A meta-analysis of randomized controlled trails. JAMA 2006;295:2046-56.

Baigent C, for the Cholesterol Treatment Trialists’ (CTT) Collaborators. Efficacy and safety of cholesterol-lowering treatment: prospective meta-analysis of data from 90,056 participants in 14 randomized trials of statins. Lancet 2005;366:1267-78.

LaRosa, et al for the Treating to New Targets (TNT) Investigators. Intensive lipid lowering with atorvastatin in patients with stable coronary disease. NEJM 2005;352:1425-35.

Studer M et al. Effect of different antilipidemic agents and diets on mortality. A systematic review. Arch Intern Med 2005;165:725-30.

Hebert PR, et al. Cholesterol lowering with statin drugs, risk of stroke, and total mortality:  an overview of randomized trials. JAMA 1997; 278:313-21.

ALLHAT officers & coordinators. Major outcomes in moderately hypercholeserolemic, hypertensive patients randomized to pravastatin vs usual care. The Antihypertensive and lipid-lowering treatment to prevent heart attach trial (ALLHAT-LLT). JAMA 2002;288:2998-07.

Shepherd J, et al. Pravastatin in elderly individuals at risk of vascular disease (PROSPER): a randomized controlled trial. Lancet 2002;360:1623-30.

Corti MC, et al. Clarifying the direct relation between total cholesterol levels and death from coronary heart disease in older persons. Ann Intern Med. 1997;126:753-60.

Frolkis JP, et al. Statin do not meet expectations for lowering low-density lipoprotein cholesterol levels when used in clinical practice. Am J Med 202; 113:625-9.

Beckett N, et al. Is it advantageous to lower cholesterol in the Elderly hypertensive? Cardiovasc Drugs Ther 2000; 14:397-405.

Behar S, et al. Low total cholesterol is associated with high total mortality in patients with coronary heart disease. The Bezafibrate Infarction Prevention (BIP) Study Group. Eur Heart J. 1997;18:52-9.

Beers MH.  Explicit criteria for determining potentially inappropriate medication use by the elderly.  Arch Intern Med. 1997; 157:1531-7.

Collins R, et al. Effects of cholesterol-lowering with simvastatin on stroke and other major vascular events in 20,536 people with cerebrovascular disease or other high-risk conditions. Lancet 2004; 363:757-67.

Roberts, Barbara.  The Truth About Statins.  2012. Pocket Books.