Deprescribing may help in reducing inappropriate medication use and adverse events, but for cardiovascular care in the elderly, eliminating statins among patients taking other medications may have negative effects that far outweigh the benefits, a new study suggests.
In a large cohort study, researchers found that the withdrawal of statins from an elderly population receiving polypharmacy was associated with an increase in the risk for hospital admission for heart failure and any cardiovascular outcome, as well as death from any cause.
Statins are “lifesaving” drugs, and “according to the findings of our study, the discontinuation of this therapy has significant effects,” lead study author Federico Rea, PhD, research fellow, Laboratory of Healthcare Research and Pharmacoepidemiology, the Department of Statistics and Quantitative Methods, the University of Milano-Bicocca, Milan, Italy, told theheart.org | Medscape Cardiology.
The article was published online June 14 in JAMA Network Open.
Negative clinical consequences, including adverse drug reactions leading to hospitalizations, are causing more physicians to consider deprescribing as a way to reduce problems associated with polypharmacy, the researchers note.
Statins are “the most widely prescribed medication in the Western world, being a pivotal component in the primary and secondary prevention of cardiovascular (CV) diseases,” they write, but because randomized trials usually exclude patients with serious clinical conditions, the precise role statins play for frail patients, such as those with polypharmacy, “is still unclear.”
The population-based cohort study examined 29,047 Italian residents aged 65 years and older who were receiving uninterrupted treatment with statins as well as blood pressure–lowering, antidiabetic, and antiplatelet agents over 16 months. The follow-up period was more than 3 years.
The cohort members were followed to identify those for whom statins were discontinued. Those who continued taking other therapies during the first 6 months after stopping statins were propensity score matched in a 1:1 ratio with patients who did not discontinue taking statins or other drugs. The patient pairs were then followed for fatal and nonfatal outcomes to estimate the risk associated with statin discontinuation.
Of the overall cohort exposed to polypharmacy, 5819 (20.0%) discontinued statins while continuing to take their other medications. Of those, 4010 were matched with a comparator.
Compared with the maintaining group, those who discontinued statins had the following outcomes:
an increased risk for hospital admissions for heart failure (hazard ratio [HR], 1.24; 95% CI, 1.07 – 1.43)
any cardiovascular outcomes (HR, 1.14; 95% CI, 1.03 – 1.26)
death from any cause (HR, 1.15; 95% CI, 1.02 – 1.30)
emergency admissions for any cause (HR, 1.12; 95% CI, 1.01 – 1.19)
The increased risk occurred in patients with mild or severe profiles, regardless of gender and whether statins were prescribed as primary or secondary CV prevention.
“We expected that the discontinuation of statins could reduce the risk of access to the emergency department for neurological causes, considered a proxy for the onset of episodes of delirium, [but] this was not observed, suggesting that statin therapy has essential benefits on the reduction of fatal/nonfatal cardiovascular events with no harm effect,” said Rea, “at least considering major adverse events like hospital and emergency department admissions.”
Findings No Surprise
Neil Stone, MD, Bonow Professor of Medicine (Cardiology) and Preventive Medicine at Northwestern University’s Feinberg School of Medicine, Chicago, Illinois, says the study results aren’t surprising.
“Older patients have a higher absolute risk of dying, and withdrawing proven therapy shown to reduce risk of coronary/stroke events in randomized controlled trials would be expected to result in more cardiovascular events,” Stone said.
Although polypharmacy is a concern for the elderly and is a factor in decreased adherence, he said better solutions are needed than withdrawing proven, effective therapy. “In that sense, this study indirectly supports more research in the use of polypills to address cardiovascular risk factors,” he said. Giving a single pill that combines medications of proven value in reducing blood pressure and cholesterol might be preferable to reducing the total number of medications.
Given the complexity of polypharmacy, the study investigators say more attention is needed from all healthcare professionals who care for elderly patients.
“We hope that future studies can shed light on the best way to balance the undeniable benefit of [statins] and the harms, especially among the elderly exposed to polypharmacy,” said Rea.
Further research is also needed into why statins are discontinued in the first place, adds Stone. “We know that statins often are stopped due to symptoms that on further scrutiny may not be related to statin use,” he said.
The study was funded by grants from Fondo d’Ateneo per la Ricerca and Modelling Effectiveness, Cost-effectiveness, and Promoting Health Care Value in the Real World: the Motive Project from the Italian Ministry of the Education, University and Research. Corrao has served on the advisory board of Roche and has received grants from Bristol-Myers Squibb, GlaxoSmithKline, and Novartis outside the submitted work. The other authors have disclosed no relevant financial relationships.
JAMA Netw Open. Published online June 14, 2021. Full text
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