Should an 81-year-old healthy male with good functional status be started on a statin (HMG-CoA reductase inhibitor)?

From the Guidelines

Starting a healthy 81-year-old male with good functional status on a statin is not recommended based on current guidelines. The US Preventive Services Task Force (USPSTF) concludes that the evidence is insufficient to determine the balance of benefits and harms of initiating statin use for the primary prevention of CVD events and mortality in adults 76 years and older without a history of CVD 1. When considering statin therapy in this age group, it is essential to individualize the decision, taking into account the patient's cardiovascular risk factors, life expectancy, and potential benefits versus risks. Some key points to consider include:

• The patient's cardiovascular risk factors, such as dyslipidemia, diabetes, hypertension, or smoking
• The potential benefits of statin therapy in primary prevention, which may be modest in this age group
• The potential risks and adverse effects of statin therapy, including myalgias, cognitive effects, and drug interactions due to polypharmacy
• The importance of discussing goals of care and monitoring for adverse effects with the patient
• The need for regular follow-up with lipid panels and liver function tests to monitor the effectiveness and safety of statin therapy. In general, a moderate-intensity statin like atorvastatin 10-20 mg daily or rosuvastatin 5-10 mg daily might be considered for patients with established atherosclerotic cardiovascular disease (ASCVD), diabetes, or multiple risk factors, but the decision to initiate statin therapy in a healthy 81-year-old male should be made on a case-by-case basis, prioritizing the patient's quality of life and potential benefits versus risks 1.

From the FDA Drug Label

Rosuvastatin tablets are an HMG Co-A reductase inhibitor (statin) indicated: ( 1) To reduce the risk of major adverse cardiovascular (CV) events (CV death, nonfatal myocardial infarction, nonfatal stroke, or an arterial revascularization procedure) in adults without established coronary heart disease who are at increased risk of CV disease based on age, high-sensitivity C-reactive protein (hsCRP) ≥2 mg/L, and at least one additional CV risk factor. The decision to start an 81-year-old healthy male with good functional status on a statin should be based on his individual CV risk factors.

• Age is a risk factor, but the label does not specify an upper age limit for initiation.
• The presence of additional CV risk factors and hsCRP ≥2 mg/L would support the use of rosuvastatin to reduce the risk of major adverse CV events. Given the information provided, it is unclear if the patient has additional CV risk factors or an elevated hsCRP. Therefore, the answer to whether to start this patient on a statin cannot be determined from the label alone 2.

From the Research

Statin Therapy for an 81-Year-Old Healthy Male

• The decision to start an 81-year-old healthy male with good functional status on a statin should be based on individualized clinical reasoning, considering the patient's overall health, cardiovascular risk factors, and potential benefits and harms of statin therapy 3.
• Current guidelines recommend statins as a first-line therapy for the primary and secondary prevention of atherosclerotic cardiovascular disease (ASCVD) 4, 5.
• However, the studies provided do not specifically address the use of statins in healthy 81-year-old males with good functional status.
• The use of statins in older adults is a complex issue, and the decision to initiate statin therapy should be made on a case-by-case basis, taking into account the patient's individual characteristics, preferences, and values 3.
• Alternative lipid-lowering therapies, such as ezetimibe and PCSK9 inhibitors, may be considered for patients who are intolerant to statins or require additional LDL-C reduction 6, 7.

Considerations for Statin Therapy in Older Adults

• The potential benefits of statin therapy in older adults must be weighed against the potential risks, including adverse effects and drug interactions 4, 5.
• Clinical reasoning and individualized decision-making are essential in determining the best course of treatment for older adults, as evidence-based guidelines may not always apply to individual patients 3.
• The use of PCSK9 inhibitors and ezetimibe may be considered as alternative or adjunctive therapies for patients who require additional LDL-C reduction or are intolerant to statins 6, 7.