At what age should statin (HMG-CoA reductase inhibitor) therapy be discontinued?

When to Stop Prescribing Statins Based on Age

It may be reasonable to stop statin therapy in adults 75 years of age or older when functional decline (physical or cognitive), multimorbidity, frailty, or reduced life expectancy limits the potential benefits of statin therapy. 1

Age-Based Recommendations for Statin Therapy

For Adults Over 75 Years

• Primary Prevention (no existing cardiovascular disease):

  • Evidence is insufficient to determine the balance of benefits and harms for initiating statins in adults 76 years or older 2
  • If considering initiation, moderate-intensity statins may be reasonable (Class IIb, Level B-R) for those with LDL-C levels of 70-189 mg/dL 1
  • In adults 76-80 years with LDL-C 70-189 mg/dL, measuring coronary artery calcium (CAC) may help identify those with CAC score of zero who can avoid statin therapy 1

• Secondary Prevention (existing cardiovascular disease):

  • Continuing statin therapy is reasonable in adults >75 years who are already on statins and tolerating them well 1
  • Moderate-intensity statins are preferred over high-intensity statins in this age group 1

Decision Algorithm for Statin Discontinuation

Consider Stopping Statins When:

1. Functional Decline:

   • Significant physical limitations affecting activities of daily living
   • Cognitive impairment affecting medication adherence or quality of life

2. Multimorbidity and Frailty:

   • Multiple comorbid conditions that limit life expectancy
   • Frailty syndrome with weight loss, weakness, and decreased physical activity
   • Increased risk of falls or injury

3. Limited Life Expectancy:

   • Estimated life expectancy <5 years due to age or comorbidities
   • Terminal illness or palliative care status

4. Medication Burden:

   • Polypharmacy concerns with high risk of drug interactions
   • Statin-associated symptoms more problematic in elderly patients 3

5. Patient Preference:

   • After shared decision-making discussion about limited evidence for benefit

Practical Considerations

Monitoring Older Adults on Statins

• Assess for statin-associated symptoms more frequently in older adults
• Monitor for drug-drug interactions, especially with polypharmacy
• Evaluate functional status periodically to determine ongoing benefit

Risk-Benefit Assessment

• The benefit of high-intensity statins appears limited in the very elderly (>75 years) considering the higher potential for adverse drug reactions 4
• Adverse drug reactions are more frequent in the very elderly (4.4%) compared to younger elderly (2.7%) 4

Special Situations

For Those Already on Statins

• If a patient >75 years is already on statin therapy for diabetes mellitus and tolerating it well, it is reasonable to continue 1
• Consider dose reduction rather than complete discontinuation if mild side effects develop

For Those with High Cardiovascular Risk

• Despite age considerations, patients with multiple ASCVD risk factors (hypertension, smoking, diabetes, dyslipidemia) may still benefit from continued statin therapy 1

The evidence for statin therapy in older adults is less robust than in younger populations, with guidelines acknowledging insufficient evidence for strong recommendations in patients >75 years. The decision to discontinue statins should carefully weigh cardiovascular risk reduction benefits against quality of life, medication burden, and life expectancy considerations.