Cholesterol drugs in the elderly

[ferco]

Someone asked recently about their 80 y/o mother in a nursing home being on Lipitor. It didn't sound like such a good idea. She's never had a heart attack or stroke. What is the doctor trying to prevent....the inevitable.I would imagine a baby aspirin a day should be enough. Your thoughts.

 

[Rich_by_the_Bay]

Someone asked recently about their 80 y/o mother in a nursing home being on Lipitor. It didn't sound like such a good idea. She's never had a heart attack or stroke. What is the doctor trying to prevent....the inevitable.I would imagine a baby aspirin a day should be enough. Your thoughts.

Incomplete information, but barring oddball issues I tend to agree with you. The drug is not cheap either.

OTOH, there are some patients with underlying metabolic disorders, certain diabetics and other situations where the need is greater than the risk. That is, they have such aggressive atherosclerosis that the risk of an impending catastrophe is high and reducible.

Recent data are showing that statins may also reduce the risk of stroke, so it's possible that the drug is being given wisely. That's the thing about medicine -- every case has its twists and turns which make generalizing very dicey.

Point well taken, nonetheless. There comes a time where diminishing returns factor in.

 

[Buckeye]

We just discovered that my 92.5 year old MIL was prescribed Lipitor by her doctor at her last routine visit. She has no health issues other than high cholesterol. Her health is excellent and always has been. What is he thinking?

 

[theloneranger]

My 99 YO grandmother has high cholesterol also, with no other predisposing factors. In my opinion there is little need for Lipitor or other such medications if high cholesterol is the only thing going on.

 

[Buckeye]

What really made us mad was that he didn't even explain to her what it was for. He just gave her the script and told her she should take it. She was a little upset too when she found out what it was for and that he hadn't even discussed it with her. We told her to never fill a prescription without understanding EXACTLY what it is for. No more doctor's visits on her own! Too often, the elderly are intimidated by doctors and don't push back. She thought she had found a good doc but now she's lost confidence in him.

 

[spideyrdpd]

At what age to you decide to stop looking at options ?

You do realize the doc may have discussed something with her and she doesnt remember. Its intimidating for everyone. Young and old and people dont always listen/remember things. Especially when its medical for some reason.

even at a couple of bucks a day. I dont really see an issue with talking a lipitor. If she doesnt have insurance you can go zocor/pravachol and get a generic.
Its little to spend for a few more years of retirement.

I guess I really dont see it as a big deal since I see how much stuff they do to people in the hospital. Sick and dying people get all kinds of unneeded stuff done.

Rob

 

[Buckeye]

It not necessarily the cost of the Lipitor as she has excellent insurance but the list of side effects is long. Doesn't it have the potential of messing with her liver among other things? And it's an unnecessary cost to the system. Why should any insurance company be paying for something that is not appropriate? Waste is waste and there is a ton of it in healthcare. She has probably had high cholesterol for 20-30 years. Why worry about it now? Let someone who needs insulin to live use the healthcare dollars.

Yes, I do understand she may have "forgotten" what the doctor said during her appointment although she doesn't forget other things. Quite amazing at her age. Our solution is that she does not go to doctor's appointments alone any more.

 

[Buckeye]

http://www.doctorevidence.com/pdf/SL092005.pdf

This article addresses the question I am asking which is "if the patient has no history of heart disease (self or family), no high blood pressure, no smoking (ever), and no diabetes, then is Lipitor appropriate?" From all that I read, Lipitor is shown to be effective in reducing heart attacks in people with high cholesterol in the presence of other cardiac risk factors.

My MIL has no other risk factor than high cholesterol so why should she take a drug that has possible side effects when the drug has never been studied for her "high cholesterol only" condition? I will give her the info and let her decide.

I also found out MIL learned about Lipitor being prescribed when the Dr.'s office called her at home after her appointment and told her a prescription for Lipitor had been called into her pharmacy.

 

[Peaceful_Warrior]

Anybody on cholesterol reducing drugs absolutely needs to be taking CoEnzyme Q10 supplements. The Canadian government requires those drugs to state, on the labeling, that it must be taken with CoQ10.

Funny how US companies omit this information.

That said, there's also natural ways to reduce cholesterol through diet, exercise, and supplements. I had high cholesterol and my doctor said if I didn't improve, he'd put me on drugs.

Well, I knew not to go that route. So though I didn't increase my exercise, I did make some minor modifications to my diet (I already ate primarily low fat / low cholesterol), and added a few key supplements and my cholesterol is now not only good, but borderline "optimal."

 

[Rich_by_the_Bay]

Anybody on cholesterol reducing drugs absolutely needs to be taking CoEnzyme Q10 supplements. The Canadian government requires those drugs to state, on the labeling, that it must be taken with CoQ10.

Funny how US companies omit this information.

Coenzyme Q10 is one of many intracellular chemicals involved in the severe myopathy experienced by 1 in 1000 patients on statins. There is no credible evidence that its use is or isn't effective in preventing or treating that condition. Those studies remain to be done and done well; with a prevalence of just 1:1000 that would be a huge study to do with statistical power.

I am glad that the FDA (and even the drug companies, of whom I am often not a fan) has a policy of not making recommendations on matters which lack scientific evidence.

OTOH, a sound decision analysis might well support NOT giving statins to elderly patients who lack significant other risk factors. I usually present the numbers (including cost) to the patient and we make it a shared decision.

 

[spideyrdpd]

For many people until they have that heart attack or go in for that cardiac cath do they know if they have risk ?
I think they will eventually start giving these drugs to kids to start working on the plaque sooner.
I can tell you that its very common for the elderly to be put on these medications. Thats not to say that its right or wrong just not uncommon .

 

[Rich_by_the_Bay]

For many people until they have that heart attack or go in for that cardiac cath do they know if they have risk ?

They smoke. They have diabetes. Dad died at 48 of a heart attack. They are fat. The are sedentary. They have carotid disease or TIAs.

 

[Buckeye]

Talked to MIL about the article and the indications for taking Lipitor and her comment was "So why would I be taking this medication?" She's done with it.

 

[Rich_by_the_Bay]

Though I share a perception of overuse of statins in the elderly, just a word of caution: recent but credible evidence is showing a substantial decrease in the risk of a stroke among older patients taking statins for other reasons. IIRC, it is in the range of a relative risk reduction of about 20%, though an absolute risk reduction overall of about 1-2% per year.

Most very old people are in my experience not afraid of dying from a heart attack or anything else. What they are mortally afraid of is a stroke that leaves them unable to speak and walk, relegated to a nursing home and total care for the rest of their lives, meaning a year or two.

If I had an 88 year old patient with high cholesterol and told them that treating this with a statin would, aside from reduing their heart attack risk, also reduce their risk of a stroke by about 2% per year at a 1:1000 risk of serious side effects, then taking the drug would not be an irrational decision.

The bottom line is to communicate so the choice is informed. I wouldn't try to tell any of these generally wise very old people what the "right" decision is given the above numbers.

 

[Buckeye]

Rich - Do you know if the studies are being done on folks who have high cholesterol as the only risk factor?
MIL has no personal or family history of stroke and no other risk factors (other than being a happy and healthy 92.5).

 

[Rich_by_the_Bay]

Rich - Do you know if the studies are being done on folks who have high cholesterol as the only risk factor?
MIL has no personal or family history of stroke and no other risk factors (other than being a happy and healthy 92.5).

Buckeye, I don't have the full article available, but few studies include many patients in their 80s and above just by the demographics, and the high prevalence of other diseases that make them ineligible. So there is probably no definitive answer. But stroke is highly age related, so even if the preventive effect is constant, the absolute benefit would increase with age. And the presence of other diseases may make this even more compelling (esp diabetes which increases stroke risk).

I don't mean to be saying that anyone should take it for stroke prevention just yet -- data are suggestive but preliminary. Personally, I think it will be confirmed in future studies. It's just something to keep in mind before jumping on the wagon - the better meta-analyses (review and statistical pooling of available studies) show about a 20-24% reduction.

 

[spideyrdpd]

Hi
I have had the uncle that literally walked out of the doctors office and died of a heart attack. A neighbor who was sent home from a hospital and died that night of a heart attack. Someone who decided to take a swim and died of a heart attack.

Thats why I asked how sure can you be that they are not at risk. Interestingly the studies I read were mixed for use in the elderly. Although it seemed that the best article said that the level of the hdl was more important then the cholesterol being high.

Heres an overview that says they think its good for the elderly
I still cant find the prospect study that they refer to.

 

[Buckeye]

Spidey - was there supposed to be a link?

My MIL ain't getting out of here alive. She's had a long and healthy life and is still doing great. She knows she could go at any time and she enjoys every day. She prays she will go in her sleep. Given that she has had high cholesterol for many years and she is otherwise in excellent health (and always has been), high cholesterol might be the secret to her longevity! I guess I just don't see the need to intervene chemically when all is well.

 

[Sandy]

There is a significant concern about over medicating and unnecessarily medicating elderly and others. Side effects of many drugs and interaction effects can be siginificant. When there is not ideal communication between provider and patient, these effects can be treated with more meds.

There will continue to be emerging evidence suggesting new treatment directions for new or existing drugs. Each individual needs to assess the incremental benefit compared to the incremental risks, taking age, health, family history, etc. in its entirety.

We have seen many drugs widely used for many years only to see a rapid reversal when new information emerges (e.g. hormone replacement therapy), others do not yield the promised or promoted improvements claimed for the cost (newer antipsychotics versus older formulas), while, of course, may countless meds have improved and extended quality of life.

Caveat emptor, in this as in all else. As medicine becomes more complex, it can only help each of us to be as informed as possible - taking the same due diligence (or more) as we do all of the other major decisions and actions in our lives.

 

[Rich_by_the_Bay]

We have seen many drugs widely used for many years only to see a rapid reversal when new information emerges (e.g. hormone replacement therapy), others do not yield the promised or promoted improvements claimed for the cost (newer antipsychotics versus older formulas), while, of course, may countless meds have improved and extended quality of life.

The older and more experienced I get, the fewer prescriptions I recommend.

At my local hospital, the nurses have been overheard saying, "Here comes Dr. Rich_in_Tampa. Watch him slash and burn." While a bit of an exaggeration, the policy has stood me (and my patients) well over the years.

 

[Sandy]

The older and more experienced I get, the fewer prescriptions I recommend.

At my local hospital, the nurses have been overheard saying, "Here comes Dr. Rich_in_Tampa. Watch him slash and burn." While a bit of an exaggeration, the policy has stood me (and my patients) well over the years.

I wish more physicians had that mind set. But many have too little time and operate in a society that wants a simple solution.

As I understand some of your Dr role - it is to ensure that providers and very ill patients have the "perfect communication". When well coordinated and thought through, treatments can take critical factors as well as risks and returns into account and a "less is more" approach will generally emerge.

But, with so many variables to consider and so many unknowns, it is not any easy task to achieve that balance on your own - whether dealing with a single issue from the primary care office or more complex multi-problem situtation in a hospital.

 

[Rich_by_the_Bay]

As I understand some of your Dr role - it is to ensure that providers and very ill patients have the "perfect communication". When well coordinated and thought through, treatments can take critical factors as well as risks and returns into account and a "less is more" approach will generally emerge.

But, with so many variables to consider and so many unknowns, it is not any easy task to achieve that balance on your own - whether dealing with a single issue from the primary care office or more complex multi-problem situtation in a hospital.

Well, I oversimplified to make a point, but it can sometimes be "counter-cultural" to practice in that way. Also, there are some boundaries that need to be drawn - patients (assuming unimpaired) who are so far out there in terms of what they insist upon that I am not comfortable being their advocate; if coaching proves unsuccessful in those extreme cases, I have (rarely) bowed out.

It's alot like financial planning, really: dealing with probabilities not certainties; everyone needs to accept some risk for the best outcomes in general; complicated information to process; more than one right way to do things; highly personalized decision making; people doing foolish things despite all efforts to the contrary by others, etc.

 

[spideyrdpd]

Hi
I hate when I forget to put in the link. This is a conclusion of the study.
I agree that in many cases doctors tend to overprescribe.On the other hand people living longer tend to have a lot more issues.
Osteoporosis
Arthritis
Diabetes
Blood pressure
cholesterol
So you can expect more medications. Although now a days many of the drug companies are slick . You have pills that have more than one medication. The idea is to improve compliance, but its also good for there bottom line. Since they have a new patent and no generic competion .

http://www.medscape.com/viewarticle/444971
Conclusions
The results of PROSPER clearly show that the benefits of statin therapy observed among middle-aged adults are extended to include older patients (> 70 years). Pravastatin, at a dose of 40 mg, was well tolerated and achieved a 15% relative risk reduction in the primary endpoint at 3.2 years follow-up. Treated patients had coronary events significantly reduced by 19% and coronary mortality by 24%; however, the drug did not seem to have an effect on stroke or cognitive function. These results emphasize the need to expand statin therapy to include this elder patient population in order to reduce the incidence of vascular-related events.

 

[Tekward]

Here is a related study that questions the overprescription of statins:

http://www.overdosedamerica.com/images/LANCET LIPID-LOWERING COMMENTARY.pdf

 

[dumpster56]

We just discovered that my 92.5 year old MIL was prescribed Lipitor by her doctor at her last routine visit. She has no health issues other than high cholesterol. Her health is excellent and always has been. What is he thinking?

Something here makes no sense. The women is alive and healthy at 92+

Why lipitor? Drug companies.