In the end, STAREE will have little effect on my initiation of statins in older patients. SAGA/SITE will modestly increase my rate of statin deprescribing.
Please can we have more articles on when, who, what and why to de-prescribe?
My training in primary care covered this only slightly and most of what I picked up was from spending time with old fashioned and relatively old geriatricians who were willing to "take the risk" of stopping a medication.
Most of them worked by rules of thumb and judgement based on experience. Something that is hard to develop from scratch in a more litigious age.
Statin prescribing in older patients is a wild landscape. Everyone has their own bias and approach - and they differ widely. We have plenty of data and in the years most suited to "prevention", they make sense for many. Best to catch people in this window. But for very elderly, it is rather random - and these studies generally support that. I cannot count the number of times a patient of mine who is well into their 80s (sometimes even 90s!) will come out of the hospital on a statin if they went in with anything resembling cardiopulmonary symptoms and they're not already on a statin. It has always felt odd and futile to me to start an 87 year old on a statin! But not to everyone. Patient preference plays a huge role - and why shouldn't it? Some have suggested statins be over the counter medicine and I generally agree with that. I can also recall numerous times an end of life patient did not see the wisdom in stopping statin. Patients with metastatic cancer - even quite intelligent people who should realize what we are talking about will often look startled and decline stopping their statin. I think it comes across as the ultimate "throwing in the towel" and many are not psychologically ready for that. I agree with Adam's final take on this: it will have little effect on my initiation of statins in older patients and I think we should focus more on desprescribing in the very elderly. Would be helpful if this were more talked about in society as a whole and potentially better accepted by these very elderly.
I advised my Dad’s doctor that I wanted his Atorvastatin stopped, and this was done. But my Dad was at the time 93 years old with reasonably controlled Type 2 diabetes, easily controlled hypertension, stable iron deficiency anemia, senile sarcopenia (he weighed ~135lbs standing at ~67”), well controlled wet AMD, and 3rd degree heart block managed with a pacemaker. At the time I asked for the discontinuation of the Atorvastatin, Dad was on 5 prescription medications along with iron and retinal vitamin supplements. In that context, I was somewhat bothered that I needed to ask for the discontinuation of the statin. The doctor had been caring for Dad for ~30+ years and was otherwise good at his job.
BTW - Dad is now living in his 95th year, and he is doing quite well except for his new cognitive impairment which requires constant assistance from my sister & her husband with whom he now lives.
I am now in my 7th decade. I stopped my Atorvastatin for good this year. I had taken some drug holidays to see where my lipids stood on several occasions. My doctors always recommended I continue it. The fact that somewhat out of the blue, my HgA1c suddenly jumped to ‘pre-diabetic’ numbers and dropped down after my drug holidays helped motivate my decision to discontinue.
With respect to unexpected practice changes, one that comes to mind was the questioning of when - if ever - to use epinephrine early in out-of-hospital cardiac arrest (circa 2010).
If flow through a pipe changes to the 3rd power of the radius…. If you have plaque that is not limiting flow to the point of experiencing angina, why go after it ? Are we doing intracoronary ultrasounds to see what the true lumen was? And then, what? Cardiac PET? Haven’t we heard before that our treatment is mainly to control angina? Yes, scar tissue and ischemia might lead to arrhythmia, but, might as well bring out the Ouija board to deal with the myriad scenarios … At that age, is it not expected for it to be a stable plaque instead of one with risk for a tear and ensuing thrombotic event ? The human body is a very perplexing thing. We continue being challenged and that’s why we love medicine. Love this forum and format.
As I’ve commented before, I thought this was settled law. After 75 statins can’t add a minute to your life nor stop any meaningful damage (troponin leak is not meaningful damage). Just put it in a good ASCVD Calculator and age the person under 75 because we don’t have good data over 75 and you’ll see the difference is essentially Nil. You’ll also notice you could actually achieve meaningful benefit by probably lowering their blood pressure a little more.
At age 79 my endocrinologist wanted to put me on a statin for higher than normal LDL. I said, "That is a marker. I want to see evidence of disease before I take a statin." My PCP ordered a coronary cardiac calcium scan resulting in zero plaque so no, I don't need to take a statin.
You didn’t need a CAC. Your PCP could just calculate your ASCVD score on a reliable formula and she would see that adding a statin to your regimen would move thing by 0.2% at most. And it wouldn’t move it anymore if you failed the CAC test.
As for Staree, I have the opposite take. I’ve routinely NOT offered statins in primary prevention for older folks in the past.
Now with this data, I will approach healthy robust older patients with moderate LDL elevation differently. I can tell them it won’t make them live longer, but it will reduce their risk of a first MI by a bit…but also that even in a group that proved themselves to be very keen, many won’t end up following through over time. It’s additional information to help inform their decision.
And the NNT is? and you expect a patient to make an informed decision when very smart physicians can't agree? Probably better to add Lipitor to the drinking water. Which is whaat the latest "guidelines" recommend.
Truth be told, I'm 80 and take the stuff because of an HDL of 28 and a strong family history. AM I following the science? Probably not. But my decision is formed over years. We're supposed to do this in a 15 min visit?
And, respectfully disagree. STAREE shows a clear predominance of "medically important" harms (particularly after removing the silly, panicked mid-trial addition of revascularization to the composite). Even ignoring harms there was zero beneficial effect on death, disability, dementia, or hospitalizations. All in a sample using a run-in phase!
Outside of clear, carefully consented secondary prevention, STAREE should be a clarion call to never initiate statins in older primary prevention patients. SAGA further suggests it is safe to translate this to older people taking the drugs.
Let us not forget that additional pills are always a burden, a cost, and a risk. If they are not helping in tangible, measurable ways that matter to people, it is a net negative to be on them.
“Let us not forget that additional pills are always a burden, a cost, and a risk. If they are not helping in tangible, measurable ways that matter to people, it is a net negative to be on them.” AMEN
Stopping a medication that has been “trusted” for decades—after all, that’s why we’ve kept taking it—is a surprisingly complex and personal decision. It raises some deep questions, not least: “Well, why the hell have I been taking this for the last 20 years?” And for many of us, it summons an almost visceral response to the ultimate question: “Do I really want to be the smartest person in the cemetery?”
Really it’s all about educating our patients. Aren’t we supposed to be doing that all the time.? I do teach my residents never to stop a medicine on the first visit unless it’s exceedingly dangerous because of what you said. But then, as the patient gets to trust you, you could start talking with them about de prescribing.
In 2002, my 82-year-old grandmother laid in a hospice bed 2 weeks away from passing away. She had survived breast, colon, and endometrial cancer, but her heart was fine, short of being 82 years old. She was having difficulty swallowing anything, especially pills. The hospice nurses (on orders written by her doctor) were still giving her atorvastatin. Needless to say, I deprescribed it myself by washing them down the sink through the disposal. I know, we are not supposed to do that, but someone somewhere said they should be in the water supply anyway, and it's what I had on hand that I knew would make sure she never got forced to take another one. I started deprescribing them routinely in my elderly patients who were taking them for primary prevention after that (after a conversation with said patient). I finally feel vindicated with this study. To me, it was just logical.
As long as the prescription was filled, even if it wasn’t taken, the doc doesn’t get dinged by metrics penalties….no one loses …. The constant trying to make everything white or black and the pigeonholing of segments of the population that are diverse and didn’t read the textbooks… no wonder the studies are not being helpful in determining pros and cons. Individualized therapy is needed. The metrics help ambulance chasers by trying to show a deviation from “ the standards “, quick sand everywhere. Should the words Standard and Guideline be avoided ? We already have Usual and Customary .
Here is where helping decrease morbidity is better than preventing mortality.
OK: the statin group didn’t live longer but they had less MIs. That’s good, right? Having an MI can cause distress, a procedure, a hospital stay that could cause iatrogenic complications, etc etc.
So if they lived the same amount but with better quality of life, isn’t this also important?
2% reduction in non-fatal MI…NNT 50. I will mull this over for myself: a 65 year-old female with a family history of early cardiac death (brother), an LDL 138, HDL 69, Lp(a) 27, normal stress test, but aortic calcifications shown on some imaging. Normal BP on 12.5 mg daily losartan.
I’ve declined a statin offer from my PCP for years. I REALLY don’t like taking pills.
Of course you should make decisions about what meds you take with your doctor. All I am saying is that we should not dismiss the study out of hand as not useful, just because mortality wasn’t affected.
I think you have a good point. To me, it gives justification for deprescribing in those who want to or in those who have other medical conditions that are more likely to kill them than an MI. It gives us data to present to the patient to help them help us make the decision.
I loved "Because as you get older, targeting one disease, even if it is the most common killer, does not make a difference in the face of everything else conspiring to kill you."
Comes an age where just breathing might conspire to kill you.
Excellent article Dr Cifu.
Please can we have more articles on when, who, what and why to de-prescribe?
My training in primary care covered this only slightly and most of what I picked up was from spending time with old fashioned and relatively old geriatricians who were willing to "take the risk" of stopping a medication.
Most of them worked by rules of thumb and judgement based on experience. Something that is hard to develop from scratch in a more litigious age.
Statin prescribing in older patients is a wild landscape. Everyone has their own bias and approach - and they differ widely. We have plenty of data and in the years most suited to "prevention", they make sense for many. Best to catch people in this window. But for very elderly, it is rather random - and these studies generally support that. I cannot count the number of times a patient of mine who is well into their 80s (sometimes even 90s!) will come out of the hospital on a statin if they went in with anything resembling cardiopulmonary symptoms and they're not already on a statin. It has always felt odd and futile to me to start an 87 year old on a statin! But not to everyone. Patient preference plays a huge role - and why shouldn't it? Some have suggested statins be over the counter medicine and I generally agree with that. I can also recall numerous times an end of life patient did not see the wisdom in stopping statin. Patients with metastatic cancer - even quite intelligent people who should realize what we are talking about will often look startled and decline stopping their statin. I think it comes across as the ultimate "throwing in the towel" and many are not psychologically ready for that. I agree with Adam's final take on this: it will have little effect on my initiation of statins in older patients and I think we should focus more on desprescribing in the very elderly. Would be helpful if this were more talked about in society as a whole and potentially better accepted by these very elderly.
Great comment, thanks.
Adam
I advised my Dad’s doctor that I wanted his Atorvastatin stopped, and this was done. But my Dad was at the time 93 years old with reasonably controlled Type 2 diabetes, easily controlled hypertension, stable iron deficiency anemia, senile sarcopenia (he weighed ~135lbs standing at ~67”), well controlled wet AMD, and 3rd degree heart block managed with a pacemaker. At the time I asked for the discontinuation of the Atorvastatin, Dad was on 5 prescription medications along with iron and retinal vitamin supplements. In that context, I was somewhat bothered that I needed to ask for the discontinuation of the statin. The doctor had been caring for Dad for ~30+ years and was otherwise good at his job.
BTW - Dad is now living in his 95th year, and he is doing quite well except for his new cognitive impairment which requires constant assistance from my sister & her husband with whom he now lives.
I am now in my 7th decade. I stopped my Atorvastatin for good this year. I had taken some drug holidays to see where my lipids stood on several occasions. My doctors always recommended I continue it. The fact that somewhat out of the blue, my HgA1c suddenly jumped to ‘pre-diabetic’ numbers and dropped down after my drug holidays helped motivate my decision to discontinue.
With respect to unexpected practice changes, one that comes to mind was the questioning of when - if ever - to use epinephrine early in out-of-hospital cardiac arrest (circa 2010).
Best of luck with your Dad.
Adam
If flow through a pipe changes to the 3rd power of the radius…. If you have plaque that is not limiting flow to the point of experiencing angina, why go after it ? Are we doing intracoronary ultrasounds to see what the true lumen was? And then, what? Cardiac PET? Haven’t we heard before that our treatment is mainly to control angina? Yes, scar tissue and ischemia might lead to arrhythmia, but, might as well bring out the Ouija board to deal with the myriad scenarios … At that age, is it not expected for it to be a stable plaque instead of one with risk for a tear and ensuing thrombotic event ? The human body is a very perplexing thing. We continue being challenged and that’s why we love medicine. Love this forum and format.
This discussion and presentation is very helpful!!
“…that shed light on when we should stop starting or start stopping statins. (I deeply love that sentence.)”
Me too—and those are the important questions.
Thanks, Dr. Cifu, for a good, practical appraisal and for sharing your takeaways for implementation.
As I’ve commented before, I thought this was settled law. After 75 statins can’t add a minute to your life nor stop any meaningful damage (troponin leak is not meaningful damage). Just put it in a good ASCVD Calculator and age the person under 75 because we don’t have good data over 75 and you’ll see the difference is essentially Nil. You’ll also notice you could actually achieve meaningful benefit by probably lowering their blood pressure a little more.
At age 79 my endocrinologist wanted to put me on a statin for higher than normal LDL. I said, "That is a marker. I want to see evidence of disease before I take a statin." My PCP ordered a coronary cardiac calcium scan resulting in zero plaque so no, I don't need to take a statin.
You didn’t need a CAC. Your PCP could just calculate your ASCVD score on a reliable formula and she would see that adding a statin to your regimen would move thing by 0.2% at most. And it wouldn’t move it anymore if you failed the CAC test.
I will have to read the deprescribing paper.
As for Staree, I have the opposite take. I’ve routinely NOT offered statins in primary prevention for older folks in the past.
Now with this data, I will approach healthy robust older patients with moderate LDL elevation differently. I can tell them it won’t make them live longer, but it will reduce their risk of a first MI by a bit…but also that even in a group that proved themselves to be very keen, many won’t end up following through over time. It’s additional information to help inform their decision.
So, innocence, you’re stopping at troponon leak. Now they won’t live longer and they won’t live better so what’s the idea?
Avoiding an index MI, an admission, and an invasive procedure is not nothing in my book. YMMV.
And it’s not my decision. So I’ll offer the data to patients, and let them decide with the latest information that we have.
And the NNT is? and you expect a patient to make an informed decision when very smart physicians can't agree? Probably better to add Lipitor to the drinking water. Which is whaat the latest "guidelines" recommend.
Truth be told, I'm 80 and take the stuff because of an HDL of 28 and a strong family history. AM I following the science? Probably not. But my decision is formed over years. We're supposed to do this in a 15 min visit?
ARR for non fatal MI was 1.2% I believe, over nearly 6 years. NNT of about 83. Like I said, it reduces their risk of index MI “a bit”.
Yes, I expect a patient to make a decision for themselves, after I inform them. I’m not their dad.
I never said I endorse the latest guidelines. But you’ll get nowhere arguing against straw men with me.
Never said this job is easy (although it’s not like I’m laying bricks in 110F heat….now THAT is hard work). But it’s what I’ve signed up to do.
Wonderful piece, as always.
And, respectfully disagree. STAREE shows a clear predominance of "medically important" harms (particularly after removing the silly, panicked mid-trial addition of revascularization to the composite). Even ignoring harms there was zero beneficial effect on death, disability, dementia, or hospitalizations. All in a sample using a run-in phase!
Outside of clear, carefully consented secondary prevention, STAREE should be a clarion call to never initiate statins in older primary prevention patients. SAGA further suggests it is safe to translate this to older people taking the drugs.
Let us not forget that additional pills are always a burden, a cost, and a risk. If they are not helping in tangible, measurable ways that matter to people, it is a net negative to be on them.
“Let us not forget that additional pills are always a burden, a cost, and a risk. If they are not helping in tangible, measurable ways that matter to people, it is a net negative to be on them.” AMEN
Stopping a medication that has been “trusted” for decades—after all, that’s why we’ve kept taking it—is a surprisingly complex and personal decision. It raises some deep questions, not least: “Well, why the hell have I been taking this for the last 20 years?” And for many of us, it summons an almost visceral response to the ultimate question: “Do I really want to be the smartest person in the cemetery?”
Really it’s all about educating our patients. Aren’t we supposed to be doing that all the time.? I do teach my residents never to stop a medicine on the first visit unless it’s exceedingly dangerous because of what you said. But then, as the patient gets to trust you, you could start talking with them about de prescribing.
Regarding being the smartest person in the cemetery—the results showed no difference in overall mortality……
SO well said. Thanks, Len.
Adam
In 2002, my 82-year-old grandmother laid in a hospice bed 2 weeks away from passing away. She had survived breast, colon, and endometrial cancer, but her heart was fine, short of being 82 years old. She was having difficulty swallowing anything, especially pills. The hospice nurses (on orders written by her doctor) were still giving her atorvastatin. Needless to say, I deprescribed it myself by washing them down the sink through the disposal. I know, we are not supposed to do that, but someone somewhere said they should be in the water supply anyway, and it's what I had on hand that I knew would make sure she never got forced to take another one. I started deprescribing them routinely in my elderly patients who were taking them for primary prevention after that (after a conversation with said patient). I finally feel vindicated with this study. To me, it was just logical.
As long as the prescription was filled, even if it wasn’t taken, the doc doesn’t get dinged by metrics penalties….no one loses …. The constant trying to make everything white or black and the pigeonholing of segments of the population that are diverse and didn’t read the textbooks… no wonder the studies are not being helpful in determining pros and cons. Individualized therapy is needed. The metrics help ambulance chasers by trying to show a deviation from “ the standards “, quick sand everywhere. Should the words Standard and Guideline be avoided ? We already have Usual and Customary .
Doc writes the prescription... Patient goes to the pharmacy and gets the box of pills...
"responsible" doc, "compliant" patient.
Then who cares if the pills go down the patient's digestive system or go down the drain.
Here is where helping decrease morbidity is better than preventing mortality.
OK: the statin group didn’t live longer but they had less MIs. That’s good, right? Having an MI can cause distress, a procedure, a hospital stay that could cause iatrogenic complications, etc etc.
So if they lived the same amount but with better quality of life, isn’t this also important?
2% reduction in non-fatal MI…NNT 50. I will mull this over for myself: a 65 year-old female with a family history of early cardiac death (brother), an LDL 138, HDL 69, Lp(a) 27, normal stress test, but aortic calcifications shown on some imaging. Normal BP on 12.5 mg daily losartan.
I’ve declined a statin offer from my PCP for years. I REALLY don’t like taking pills.
Of course you should make decisions about what meds you take with your doctor. All I am saying is that we should not dismiss the study out of hand as not useful, just because mortality wasn’t affected.
I think you have a good point. To me, it gives justification for deprescribing in those who want to or in those who have other medical conditions that are more likely to kill them than an MI. It gives us data to present to the patient to help them help us make the decision.
This makes sense.
I loved "Because as you get older, targeting one disease, even if it is the most common killer, does not make a difference in the face of everything else conspiring to kill you."
Comes an age where just breathing might conspire to kill you.
Thanks! I was really into that sentence too.