Statin Prescribing in the Elderly: Special Considerations

Our aim was to examine the current evidence behind prescribing statins to individuals over 65 years of age with emphasis on those older than 75. Individuals over 75 years of age may often have multiple comorbidities and take many medications. Additionally, they are often underrepresented in randomized controlled trials (RCTs) of statins in older populations. While results of RCTs demonstrate the benefit of statin therapy in both primary and secondary prevention patients, clinicians must more carefully consider adverse effects and drug-drug interactions before prescribing statin therapy as well as determining the intensity in older individuals.

Four primary prevention trials support statins for primary prevention following a clinician-patient risk discussion. Of these, JUPITER and HOPE-3 studied participants 70 years of age and over who derived benefit. However, in those over 85 years, available information is inadequate to guide decisions regarding statin therapy. Documented statin adverse effects include new onset diabetes, myopathy, and medication interactions. Although cognitive decline has been reported anecdotally, its incidence was comparable to placebo in two RCTs with validated cognitive evaluations. Concerns about significant liver and kidney injury with statins were not corroborated in RCTs. For most patients, the potential for reducing ASCVD risk outweighs possible adverse effects; however, in the elderly, the impact of drug treatment on cognition, musculoskeletal ability, and independence must be heavily weighed. Given the limited high quality evidence for primary prevention in individuals over 75 years of age, neither the ACC-AHA nor USPSTF cholesterol guidelines recommend statin therapy for primary prevention in this patient population. If prescribed, physician judgment and shared decision-making are crucial. To aid clinicians, imaging studies of subclinical atherosclerosis may improve specificity of statin therapy to prevent ASCVD in the elderly in primary prevention.