Statin use in older people
Over the past decade there have been increasing concerns raised by some people in the medical field and many members of the public about the increasing prescriptions written for statin drugs (e.g. Crestor, Lipitor, Zocor & Pravachol, along with the numerous generics) and the potential over-reporting of side-effects by the public but equally the under-reporting of side-effects in the numerous clinical trials of these drugs. Most people practising medicine would support the use of statins for people who have existing heart disease but the real question is, does it benefit people purely because the cholesterol is elevated without evidence of any vascular problems?
A recent study published in JAMA-Internal Medicine journal has raised concerns about the use of statins for people without heart disease, over the age of 65. Statins are the major group of drugs used to block the production of cholesterol in the liver and have been shown in a number of trials in people with existing heart disease to reduce further cardiac events.
There is, however, no data to support the use of statins for people over the age of 75. Despite this, the use of statins in people 79 years or older has increased threefold from the 1990s until most recently. This has increased from 9% to 34% over the last decade.The researchers analysed data from a long-standing trial called ALLHAT-LLT otherwise known as the “Antihypertensive and lipid-lowering treatments to prevent heart attack trial-lipid lowering trial”. This was a placebo, controlled trial of just under 2,900 people without heart disease, where half were given Pravachol 40 mg daily and the other half usual care. Pravachol is the weakest of the 4 commonly prescribed statins. In people over the age of 65 up to age 74 there were more deaths in the statin group than the usual care group (141 versus 113). This was also the case in people older than 75 (92 deaths versus 65 deaths respectively). The rates of overall cardiovascular events were slightly lower in the statin group versus the usual care group(76 versus 89) and for those 75 or older (31 versus 39). The conclusion of the trial was that there were no benefits using statins for primary prevention in people over the age of 65. An editorial by the editor of Harvard Health publications suggested that the musculoskeletal abnormalities and potential memory problems from statin use in older people could further compromise a person’s ability to function in daily life.The conclusion of the trial was “the combination of these multiple risks and the ALLHAT-LLT data showing that statin therapy in older adults may be associated with an increased mortality rate should be considered before prescribing or continuing statins for patients in this age category.” For many years, a minority of doctors, including my colleague and friend Dr Aseem Malhotra, and I have been warning about the excessive use of statins by the medical profession. A few years back, Dr Maryanne Demasi was vilified by the medical profession following a segment on the ABC catalyst program where she dared to suggest that statin drugs were being overprescribed. Since her public vilification, the arguments put forward by Dr Demasi have been substantiated by a number of trials including the one mentioned above and it’s now time that the medical profession re-evaluated the excessive prescription of these medications. For many years, I have only prescribed statins to people who have existing cardiovascular disease such as prior heart attack, stent or coronary bypass surgery or if they have a significant load of atherosclerosis, as seen by a coronary calcium score or on carotid ultrasound. It is time that the conservative elements of medicine admit they were wrong and only prescribe statin drugs for people with appropriate indications. The first line of the Hippocratic Oath states, “First, do no harm.”
The excessive prescription of statins is certainly an extremely good example of where the medical profession can cause more harm than good.