Should a 74-year-old diabetic patient continue or initiate statin (HMG-CoA reductase inhibitor) therapy perioperatively for hip replacement surgery?

Statin Management for 74-Year-Old Diabetic Patient Undergoing Hip Replacement

Continue or initiate at least moderate-intensity statin therapy perioperatively for this 74-year-old diabetic patient, as the cardiovascular benefits substantially outweigh surgical risks, and statins should not be discontinued for elective orthopedic surgery. 1

Primary Recommendation Based on Age and Diabetes Status

For this 74-year-old diabetic patient, moderate-intensity statin therapy is the minimum recommended treatment, with consideration for high-intensity therapy if additional cardiovascular risk factors are present. 1

• Patients with diabetes aged 40-75 years without established atherosclerotic cardiovascular disease (ASCVD) should receive at least moderate-intensity statin therapy in addition to lifestyle modifications 1
• If this patient has additional ASCVD risk factors (hypertension, smoking, family history, albuminuria, or LDL ≥100 mg/dL), high-intensity statin therapy is recommended to achieve LDL cholesterol reduction of ≥50% and target <70 mg/dL 1
• Meta-analyses demonstrate a 9% reduction in all-cause mortality and 13% reduction in vascular mortality for each 39 mg/dL reduction in LDL cholesterol in diabetic patients 2

Perioperative Continuation

Do not discontinue statin therapy perioperatively for hip replacement surgery. 2

• The cardiovascular protective benefits of statins clearly outweigh any theoretical perioperative risks 2
• Statin withdrawal can precipitate acute cardiovascular events in high-risk patients
• If the patient is already on statin therapy, continuation through the perioperative period is reasonable and recommended 1

Specific Statin Selection and Dosing

Moderate-intensity options include: 1

• Atorvastatin 10-20 mg daily
• Rosuvastatin 5-10 mg daily
• Simvastatin 20-40 mg daily
• Pravastatin 40-80 mg daily

High-intensity options (if additional risk factors present): 1

• Atorvastatin 40-80 mg daily
• Rosuvastatin 20-40 mg daily

Special Considerations for Age 74

While this patient falls just below the >75 years threshold, the recommendations are clear for the 40-75 age group 1:

• For patients already on statins who turn 75, continuation is reasonable 1
• The evidence supports statin use in this age range with diabetes, as the 10-year cardiovascular risk is substantial 3
• A critical caveat: If this patient were >75 years and statin-naive, initiation would require discussion of benefits versus risks, though moderate-intensity therapy remains reasonable 1

Monitoring Requirements

Obtain baseline lipid panel before surgery if not recently done, then reassess 4-12 weeks postoperatively: 1

• Baseline lipid profile (total cholesterol, LDL, HDL, triglycerides) should be obtained before initiating statin therapy 1
• Monitor LDL cholesterol 4-12 weeks after initiation or dose adjustment 1
• Annual lipid monitoring thereafter to assess adherence and efficacy 1
• Monitor for muscle symptoms, particularly given surgical stress and potential immobility 4

Important Safety Considerations

Key adverse effects to monitor perioperatively: 4

• Myopathy risk increases with age ≥65 years, making this patient at elevated baseline risk 4
• Instruct patient to report unexplained muscle pain, tenderness, or weakness, especially important post-hip surgery when distinguishing surgical from statin-related myopathy may be challenging 4
• Risk factors for myopathy include renal impairment, hypothyroidism, and drug interactions—screen for these preoperatively 4
• Temporarily discontinue only if patient develops severe acute illness with risk of rhabdomyolysis (sepsis, shock, severe hypovolemia) 4

Glycemic Impact

Be aware that statins may modestly worsen glycemic control, but cardiovascular benefits far outweigh this risk: 4, 5

• Statins can increase HbA1c and fasting glucose levels 4
• High-intensity atorvastatin shows greater glycemic impact than moderate-intensity options 5
• Pitavastatin may have more favorable glycemic effects if this becomes a concern 5
• Optimize diabetes management perioperatively regardless of statin choice 4

Common Pitfalls to Avoid

• Do not discontinue statins perioperatively unless severe acute illness develops 2, 4
• Do not use the patient's age (74) as a reason to withhold or reduce statin intensity—this falls squarely within guideline-recommended age range 1
• Do not prescribe low-intensity statins—these are not recommended for diabetic patients and provide inadequate cardiovascular protection 1
• Do not fail to assess for additional ASCVD risk factors that would warrant high-intensity rather than moderate-intensity therapy 1

If Patient Cannot Tolerate Intended Intensity

Use the maximum tolerated statin dose rather than discontinuing therapy entirely. 1

• Even low-dose or less-than-daily statin therapy provides some cardiovascular benefit 1
• Consider alternative statins if side effects occur with initial choice 1
• If LDL goals not met on maximum tolerated statin, consider adding ezetimibe 1