‘Ageist’ statin study highlights under prescribing concerns
A leading cardiologist has railed against ageism in prescribing, after a study in the BMJ cast doubt on the value of statins for primary prevention of cardiovascular disease (CVD) in people aged over 74.
Associate Professor David Colquhoun, a clinical cardiologist and academic at the University of Queensland, urged doctors not to engage in ageism or “therapeutic nihilism”. Doctors should be guided by older patients’ individual risk when deciding whether or not to prescribe lipid-lowering therapies.
“It’s true that risk equations are not very effective when people are over 70 because age is such a strong determinant,” he said. “But waiting for people to have their first cardiovascular event before prescribing statins is not good enough either, as dropping dead is the first coronary event in around a third of cases.”
Professor Colquhoun said cardiovascular risk profiling in the elderly was best achieved using a coronary artery calcium score. Around a third of asymptomatic people 75 and older would be found to have a score over ‘400’ based on this test, meaning they should definitely be treated, he said. The patient’s out-of-pocket cost was around $150.
Professor Colquhoun was commenting on the back of a Spanish study published in the BMJ last week which sought to discern the impact of statin therapy among 46,864 people by linking prescriptions to GPs’ medical records.
The researchers compared the recorded incidence of death and atherosclerotic CVD over a decade between people who commenced statin therapy in 2006-7 (16%) and non-statin users.
In this elderly cohort, statin treatment was not associated with a reduction in mortality or atherosclerotic CVD – except if the patient had diabetes and was aged under 85, the study found.
The authors said their findings called into question the age-appropriateness of US and UK guideline recommendations that people with a 10% risk of atherosclerotic CVD at 10 years receive statins, noting the incidence of CVD in the control group was well above 10%.*
Study under fire
The study has been heavily criticised by Australian cardiologists, who still have fresh memories of thousands of Australians discontinuing their statin therapy after controversial criticism of the treatment on ABC’s Catalyst TV series in 2013.
Professor Colquhoun slammed the latest study as “data dredging” and said it was “difficult to understand how a respected medical journal such as the BMJ could publish poor research and allow unsubstantiated statements to be made which have important consequences regarding cardiovascular health.”
Unlike in a well-designed trial, the observational study could not discern whether patients actually took the drugs which were dispensed and whether there was a change in their lipid levels, he said.
“What is clear [from clinical trials, is], in the very elderly, lipid-lowering therapy and more specifically lowering of LDL-cholesterol, decreases heart attacks, but if there is a high competing cause of mortality then there is no decrease in total deaths,” Professor Colquhoun said.
Professor Garry Jennings, executive director, Sydney Health Partners said the study authors had overreached in their conclusions. “As a retrospective cohort study, definitive conclusions regarding the effectiveness of statin treatment cannot be drawn,” Professor Jennings said.
Professor John McNeil, head of the Department of Epidemiology and Preventive Medicine at Monash University said the study “casts some doubt” about the value of statins in non-diabetic adults beyond 75 who did not have a specific reason to be taking them.
However, he added: “It is by no means the last word on the subject and emphasises the importance of large-scale studies such as the [ongoing] Australian STAREE trial to resolve this question more definitively.”
Under-prescribing in aged care
Meanwhile, ageism was recently cited as a possible explanation for under-prescribing of recommended medicines in residential aged care.
According to an Australian study published in the International Journal for Quality in Healthcare last month, up to 48% of residents did not receive the recommended treatment for their condition, based on a review of 17,672 aged care residents in the Australian Government’s Department of Veterans’ Affairs database.
For instance, the study found only 52.9% of residents with a history of ischaemic heart disease or MI were being prescribed statins and only 56.1% of residents with a history of hypertension or congestive heart failure were receiving an ACE inhibitor or ARB.
The authors cited a literature review which found under-prescribing was common in older populations and was due to a multitude of factors including “multi-morbidity, ageism and economic limitations”.
Lead study author Dr Jodie Hillen (PhD) who undertook the study at the Quality Use of Medicines and Pharmacy Research Centre at UniSA told doctorportal some of the findings may reflect GPs “appropriately de-prescribing medicines in patients who require palliative care, have difficulty swallowing or who have end-stage dementia.”
“However, while de-prescribing is recommended for some medications such as statins, it is generally not recommended for patients taking ACE inhibitors or ARBs, which were also underutilised,” she said. “Further research is required to determine the reasons why beneficial medications are not being used in the older population.”
Dr Hillen and colleagues concluded their study by recommending comprehensive geriatric assessment and collaborative medication reviews to improve medication-related quality of care in aged care.
*In Australia, Guidelines for the Management of Absolute Cardiovascular Disease Risk (2012) recommend lipid lowering and BP lowering therapy for people with a greater than 15% absolute risk of CVD events over five years. The guidelines state that in adults over 74, “use clinical judgement to consider benefits and risks of treatment, co-morbidities and values before initiating therapy”.