Lipid-lowering Drug Therapy in Elderly Patients

Abstract

Coronary heart disease (CHD) is the leading cause of death among elderly patients and >80% of all coronary deaths occur in patients >65 years. Cerebrovascular events are also associated with older age. Since elevated cholesterol concentrations are a risk factor for cardiovascular disease, lipid-lowering drugs, especially statins, are in widespread use for prevention. There is substantial underutilization of statins in the elderly population although meta-analyses of randomized trials have shown that in elderly secondary prevention patients they reduce all-cause mortality by approximately 22%, CHD mortality by 30%, non-fatal myocardial infarction (MI) by 26% and stroke by 25% over a treatment period of 5 years. Relative risk reduction is greater or at least equal to the one in younger patients, but absolute risk reduction is greater in the elderly because the event rate is higher. The benefit from statin treatment seems to start beyond 1 year of treatment. Data on primary prevention in the elderly are less clear. There is a significant reduction in CHD events, CHD deaths and all-cause mortality but numbers needed to treat (NNT) are higher than in secondary prevention. Treatment decisions have to consider the individual patient's situation regarding multimorbidity, polypharmacy and patient wishes. Economic considerations have to be made in some health systems. Statins have no role in the prevention or the treatment of dementia. Statins are generally safe and safety is equal in younger and older age groups. Their prescription should not be denied to patients for reasons of age alone. Other lipid-lowering drugs play only a minor role in cardiovascular disease (CVD) event prevention because convincing outcome studies are largely missing. A primary prevention statin trial in the very elderly is urgently needed.

Older peoples’ attitudes regarding polypharmacy, statin use and willingness to have statins deprescribed in Australia

“…In older people, there is strong evidence for the effectiveness of statin therapy in secondary prevention of cardiovascular morbidity [17][18][19]. The evidence for statin use in primary prevention in this demographic is less clear [20][21][22] and yet risks of adverse effects of these medications are higher in older adults [23]. Moreover, as people age care goals may change from extending duration of life to maintaining function and quality of life.…”

Reduction of cardiovascular risk in subjects with high lipoprotein (a) levels

“…The most advanced antisense lipid-lowering agent in development is Mipomersen, an apoB-100 synthetises inhibitor. Mipomersen has been shown to significantly decrease Lp(a) concentrations by about 30% (46).…”

Prescribing appropriately in frail older people

“…For example, in one study the median life expectancy for frail older hospitalised patients with delirium was 88 days (95 % confidence interval: 5-171 days) [72]. The homeostatic instability and loss of physiological reserves of these patients renders them vulnerable to ADEs and they may not survive to reap any benefit from treatment with medications such as statins [73], angiotensinconverting enzyme inhibitors [74] or bisphosphonates [75]. Despite recent attention to incorporating patient life expectancy and goals of care into medication prescribing among older people, these criteria have yet to be implemented into medication reduction trials at the end of life.…”