Saturday, November 9, 2013

When to stop statins in the elderly

One of the challenges for me in blogging (occasionally) is that I tend to think about patients that I have just seen but due to privacy, I definitely do not want to reveal any identifying information.

One of the concepts that geriatricians get easily and intuitively is that not all medications are meant to be life long for a variety of reasons.  But that concept seems to be missed on many non geriatricians.  The following case demonstrates this point.

Recently I saw an elderly gentleman with dementia (elderly means late 80s to 90s).  He was not complicated medically. Pretty typical health issues including high blood pressure and high cholesterol.  But his major current issues was quite a sudden decline in memory, ability to care for self and weight loss.  These signs, taken together, along with his advanced age and no obvious easily reversible cause discovered leads to a very poor prognosis.  Family understood this and was asking about hospice.  The patient had a good quality of life, was comfortable and not in pain, but the family clearly wanted the goals of his care shifted to function, quality of life, maintaining independence and community at home.

When someone has an acute deterioration of their function, I cast a very wide net as to what is causing deterioration.  There's a lot that goes into that evaluation, but as a geriatrician, I always look at medications to see if a patient is taking a medication that is harmful or unnecessary.  Statins do cause side effects and they are often a medication that is potentially harmful and unnecessary (especially over short periods of time).  So for this patient, since there was no readily obvious cause of the sudden deterioration of memory, function and weight, it is worth trying to stop the statin to see if it is a culprit.  Several weeks later when I saw the patient back, I found out that the primary care doctor was too nervous to stop a statin because the man had a heart attack or stroke years (decades?) ago.

I get so used to stopping/holding/reducing meds in the face of side effects/unstable patients that I am always surprised (but shouldn't be) when another physician is too afraid to stop a medication despite staring at a symptom that well could be a side effect of the medication.

Reasons to start a statin are fairly clear: LDL higher than a certain level (100, 130 or 160) or someone who has had a heart attack, stroke or has diabetes.

But what are good, concrete reasons to stop a statin?  Well, there are no good published guidelines.  So here goes.  I'll write one!

First let me review what statins do and how they do what they do
1.  Statins prevent heart attacks in older adults.  While they prevent strokes and heart attacks in younger adults, in older adults that has not been shown to be the case.
2.  Therefore, statins are preventative medications.  They do not confer any immediate functional, comfort, therapeutic (fixing) benefit to the patient.
3.  The longer you take a statin the more effective they are.  So while a statin may help 1 in 45 patients taking a statin to prevent a heart attack over 2-3 years, over 15 years it may help 1 in 10 patients (a better ratio).  Statins are much more effective over decades.  Statins confer no benefit over months (unless you just had a heart attack or stroke).
4.  Statins can cause weakness, muscle ache, mild hepatitis as common side effects.  And they interact with other drugs.

So why stop statins? (not in any particular order)
1.  They are causing side effects.  General principle of life is that if a treatment is causing a side effect, then it isn't worth it.  Even in high risk patients, statins only benefit 1 in 10 patients over 15 years.  Most people don't benefit from these medications.  Taking a medication that is non beneficial and causing a side effect is the worst of both worlds.  Even for that 1 in 10 that may benefit over 15 years, I would argue that tolerating a side effect that long still might not be worth it.

2.  Prevention of heart attacks and strokes no longer matters.  This is true for people who are at the end of their life.  Keeping their LDL less than 100 is an abstract goal that does not matter any more.  This reason is true of almost everyone on hospice.  Sometimes treating medical problems that cause symptoms (COPD, CHF) is more important that treating medical problems that do not cause symptoms (like high cholesterol).  Prevention just stops being a priority because the symptoms that a person actively has is more important than an event that could theoretically happen.

3.  Other goals (like comfort, function, independence, quality of life) are way more important, higher priority, need more attention, are worth the energy etc.  You get my point.  It is amazing to me how doctors prioritize problems that don't match a patients priorities.  This is the flipside to point #2.  Sometimes goals just are not achieved by fixing a number on a blood test.  Statins never make anyone more comfortable and never increase function.  Most are achieved by methods not involving medications.  One of my pet peeves is that each specialist views their organ system as the most important organ system.  Doctors are not very good at prioritizing competing medical problems.

4.  Life expectancy is short.  Let me just say this-Statins do nothing over a timeframes of less than a year.  Statins work over years to decades.  Stopping a statin for the last 6 months of a person's life will not cause them to have a heart attack or stroke.  If they have a heart attack or stroke, they would have had one anyway.  No one NEEDS to die with a statin.  In fact, if someone does die of a chronic illness taking a statin up to the moment they died, I would argue that the physician was not appropriately tailoring the medications for the situation.

5.  2% is seen as a small meaningless number.  So over 2-4 years, in a general population of 100 older at-risk adults taking a statin, 2% will have a heart attack prevented.  This is a quantitative way of looking at the question.  The other would be, taking tons of pills is a big pain in the neck, or a person just isn't sold that a 2% reduction is enough to take a daily medication for 2-4 years (365 doses x 4=1460 pills!!!).  Now physicians are wired/taught/mandated/reimbursed/pressured into making every health issue seem like a BIG DEAL, but the dirty reality is whether someone takes a statin or not (over short time frames) will not likely affect their health (for better or for worse).  For my patients, whether to take something is a collaborative discussion.  Patients do get to have a say in these type of decisions. Guidelines be darned.  After all, patients ultimately have to live with the consequences.  Effectiveness is in the eye of the beholder.

6.  Lastly, it never hurts to take a break.  This isn't a reason more than it is just a plain truth (from my perspective).  Yes, for those who just had a stroke or a heart attack, there is an increase risk for another event if a statin is discontinued in the first year.  But for long term patients, stopping a statin for a short period of time (4-6 weeks) is perfectly safe (http://www.ncbi.nlm.nih.gov/pubmed/15477411).  Yes, after months and more likely years of not taking statins, there will be differences in heart attack and stroke rates (maybe strokes) but it will be minimal.

So there you have it, my reasons for stopping statins.  There are logical, concrete reasons that a person should stop taking their statin based off of ideas such as avoiding side effects, reduced efficacy, goal directed medicine and life expectancy.

8 comments:

Sten Björsell said...
This comment has been removed by a blog administrator.
Sten Björsell said...

What about hemorrhagic stroke ?
Statins reduce build up of plaque through. LDL is used to repair blood vessels. Seal leaks. But with the wrong type LDL (many/small) the system doesn't work. With statin the leak repair is reduced. Patients that has had a hemorrhagic stroke is NOT recommended to take statins. But how do we know the others in that risk zone? If studies had showed statins reduced the risk also for
hemorrhagic stroke, we would certainly have heard about them. So if they were made they were buried, can be assumed. And with such big business they were surely made....
Otherwise brain need cholesterol. Vitamin D3 is made from cholesterol. People with the highest cholesterol lived the longest, Framingham heart study...
I would,, or I have already, reduced carbohydrtaes as high blood sugar causes high triglycerides, visceral fat and reduced blood sugar regulation, which is bad for blood vessels and heart. William Davis has elaboarted on this and when a blood sugar promoting food is eliminatied, heart health like blood pressure and LDL/HDL and triglycerides are improved and calcium score scan values are improved. No statins for me !

Sten Björsell said...

Please find better software that allow editing of comments by writer!
Key- and spelling errors look poor, even to the writer!

Joshua Uy said...

Hhhmmmm.... I missed this comment.
To keep it simple, at the end of the day, I want to see a real world study to see if it works or if it doesn't. The pathophys/theory is not enough. Proof is in the pudding.

talkdat said...
This comment has been removed by a blog administrator.
Jade Graham said...

Sunan Abi Dawood in Kitaab At Tibb Book 28, Hadith 3868. Classed as Sahih by Sh. Al Albani (rahimullah)http://www.australialevitra.com/

health chronicle said...

Thanks for sharing.Reasons Why Taking Statins is Bad For You

passportt said...

my mother is 88 yrs old, has chf copd and between stage 3 & 4 kidney failure and mild diabetes managed with a pill. she used to be active enough to drive herself to the store and other appts, wear makeup and trendy clothing including accessories. she managed her bills read several publications did the crossword puzzle in the daily paper etc. she got fluid in her lungs - was put in the hospital for 10 days during which time the on call dr put her on several very strong heavy blood pressure drugs. during her stay her mind was shot she couldnt remember anything barely knew what was going on at all. she went home continuing the pills after 6 days of her mind staying a mess she had to go back to the hospital due to what the dr's there call pneumonia no matter what it is because they need an insurance code to call her problem? mean time her BP's went erratic high her blood sugar was managed with insulin which she has never used and they continued the pills given to her from the first hospital and added an antibiotic, after 8 days she was sent to a rehab home thats when i arrived there from my home in another state. ( that place almost killed her with bps over 200 and oxygen stats around 84) back to the hospital she goes for another week same pills but stopped the antibiotic. home a week chest infection eyes filled with puss a bacteria called haemophilus. more antibiotics then to a different rehab home for a week where I spoke with the dr and mentioned the over use of bp pills having started in the first hospital and her mental state being a mess. he took her off of 3 of the heavy duty pills leaving her with 3 plus some breathing treatments. at home again after about a month i had been reading about pravastatins side effects and thought maybe she could go off of it asked the blood dr what she thought - she said at 88 even though she had a plaque type heart attack 5 yrs before taking her off should not have any ill effects so i took her off. In the 2nd week my mother actually remembered something from a conversation a few hours earlier - I am certain it was due to removing the statin, i didnt mention she also had pains in her now waisted muscles which have such little strength she has trouble getting out of a chair. so now it has been 2 months- her short term memory is still pretty bad at times but life is much better for her even though it is my belief that the over use of the BP drugs expedited the onset of dementia she is still better off. she is still taking a couple of BP and heart related drugs that cause memory loss but i cannot get her drs to try to try anything different at this time. There are no geriatric drs in her area so GP's are all she can have at this time. just wanted to add my story with regard to statins.