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

Statin Discontinuation in Older Adults

For adults over 75 years of age, it is reasonable to stop statin therapy 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

Secondary Prevention (with established ASCVD)

• In patients older than 75 years with clinical ASCVD, it is reasonable to continue high-intensity statin therapy after evaluation of potential ASCVD risk reduction, adverse effects, drug-drug interactions, patient frailty, and patient preferences 1
• For patients with established ASCVD who are older than 75 years, moderate-intensity statin therapy is reasonable if high-intensity therapy cannot be tolerated 1
• Patients who are tolerating high-intensity statin therapy should continue this regimen unless contraindications develop 1

Primary Prevention (without established ASCVD)

• In adults 75 years of age or older with an LDL-C level of 70-189 mg/dL, initiating a moderate-intensity statin may be reasonable, but requires careful consideration of potential benefits and risks 1
• For adults 76-80 years of age with an LDL-C level of 70-189 mg/dL, it may be reasonable to measure coronary artery calcium (CAC) to reclassify those with a CAC score of zero to avoid statin therapy 1
• The European Society of Cardiology/European Atherosclerosis Society (ESC/EAS) recommends statins for primary prevention in patients over 75 years only if they are at high or very high risk 1

When to Consider Discontinuing Statins

Clinical Factors Supporting Discontinuation

• Functional decline (physical or cognitive) 1
• Multimorbidity that limits life expectancy 1
• Frailty syndrome 1
• Reduced life expectancy (less than 1-2 years) 1, 2
• Advanced, life-limiting illness 2

Evidence for Discontinuation

• In patients with limited life expectancy (1 month to 1 year), discontinuing statins has been shown to be safe and may improve quality of life 2
• Statin discontinuation in patients with limited prognosis resulted in:
  • No significant difference in 60-day mortality (23.8% discontinuation vs. 20.3% continuation) 2
  • Better quality of life scores 2
  • Fewer medications overall 2
  • Cost savings (approximately $716 per patient) 2

Special Considerations for Older Adults

Benefits vs. Risks

• The absolute benefits of statin therapy depend on an individual's absolute risk of vascular events and the reduction in LDL cholesterol achieved 3
• For elderly patients treated for primary prevention, the benefit-risk ratio becomes less favorable with advancing age 4, 5
• Potential statin-associated adverse events include:
  • Myopathy (muscle pain/weakness with elevated creatine kinase) - risk <0.1% 6
  • New-onset diabetes mellitus - risk ≈0.2% per year 6
  • Possible increased risk of hemorrhagic stroke 6
  • Subjective muscle symptoms (although clinical trials show minimal difference vs. placebo) 6, 3

Decision-Making Algorithm

1. Assess current health status, functional status, and life expectancy 4
2. Evaluate the presence of ASCVD (secondary prevention has stronger evidence for continuation) 1
3. Consider the patient's risk factor burden and potential benefit from continued therapy 1
4. Assess for presence of:
   • Functional decline 1
   • Multimorbidity 1
   • Frailty 1
   • Limited life expectancy 1, 2
5. Discuss risks, benefits, and patient preferences 1

Common Pitfalls and Caveats

• Failing to reassess the benefit-risk ratio of statin therapy as patients age and develop new comorbidities 4
• Continuing statins in patients with advanced illness where the potential harms may outweigh benefits 2
• Stopping statins prematurely in high-risk patients with good functional status who still have a favorable risk-benefit profile 1, 3
• Not considering that the benefits of statins take time to accrue, which may not be relevant for patients with limited life expectancy 2
• Overlooking that discontinuation of statins in patients with limited life expectancy may improve quality of life 2