At what age should HMG-CoA reductase inhibitors (statins) be discontinued?

From the Guidelines

Statins should not be automatically stopped at any specific age, but the decision to continue or discontinue therapy should be individualized based on overall health status, life expectancy, goals of care, and risk-benefit assessment, with consideration to continue current statin therapy or initiate a moderate-intensity statin in patients 75 years and older after weighing benefits and risks 1. When considering the management of statin therapy in older adults, several factors come into play, including the presence of atherosclerotic cardiovascular disease (ASCVD), diabetes, and other comorbidities.

• For patients with ASCVD, high-intensity statin therapy is recommended for those ≤75 years of age, unless contraindicated, and it is reasonable to continue statin therapy in those >75 years of age who are tolerating it 1.
• In patients with diabetes, high-intensity statin therapy should be added to lifestyle therapy for those with ASCVD, and it is reasonable to continue statin treatment in adults with diabetes aged >75 years already on statin therapy 1. Key considerations in the decision to continue or discontinue statin therapy in older adults include:
• Overall health status and life expectancy
• Presence of ASCVD or other comorbidities
• Goals of care and patient preferences
• Risk of adverse effects, such as muscle pain, cognitive effects, or drug interactions
• Potential benefits of statin therapy in reducing cardiovascular risk In general, continuing statins for cardiovascular prevention remains beneficial for healthy older adults with good functional status and life expectancy of more than 5 years 1. However, for frail elderly patients with multiple comorbidities, limited life expectancy, or those experiencing significant side effects, discontinuation may be appropriate. Common statins include atorvastatin, rosuvastatin, simvastatin, and pravastatin, and when stopping statins, it should be done under medical supervision with monitoring of lipid levels and cardiovascular risk 1.

From the Research

Statin Use and Age

• The US Preventive Services Task Force (USPSTF) recommends statin use for the primary prevention of cardiovascular disease in adults aged 40 to 75 years with one or more cardiovascular disease risk factors and an estimated 10-year cardiovascular disease event risk of 10% or greater 2.
• The USPSTF concludes that the evidence is insufficient to determine the balance of benefits and harms of statin use for the primary prevention of cardiovascular disease events and mortality in adults 76 years or older with no history of cardiovascular disease 2.
• A study on the safety and efficacy of ezetimibe/simvastatin combination versus atorvastatin alone in adults ≥65 years of age with hypercholesterolemia found that ezetimibe/simvastatin provided significantly greater improvements in key lipid parameters and higher attainment of LDL cholesterol targets than atorvastatin, with comparable tolerability 3.

Statin Therapy and Older Adults

• A systematic review and meta-analysis of randomized clinical trials on statin therapy for primary prevention of cardiovascular disease found that statin therapy was associated with reduced risk of all-cause mortality and cardiovascular events in adults at increased cardiovascular disease risk but without prior cardiovascular events, including those older than 75 years, although data for this age group were sparse 4.
• A review on the safety and efficacy of statin therapy found that the benefits of statin therapy far outweigh any real or perceived risks, including in older adults 5.

Discontinuation of Statin Therapy

• There is no clear evidence on the optimal age to stop statin therapy, but the USPSTF recommends against initiating statin therapy in adults 76 years or older with no history of cardiovascular disease due to insufficient evidence on the balance of benefits and harms 2.
• The decision to discontinue statin therapy should be individualized and based on a patient's overall health status, cardiovascular disease risk factors, and potential benefits and harms of continued therapy 5.