Level 2 [mid-level] evidence
Patients with advanced life-limiting illness commonly take a number of disease-specific medications as well as medications for symptoms and comorbidities. Polypharmacy can be associated with an increased risk of adverse events, decreased quality of life, and increased financial burden (Arch Intern Med. 2006;166:605). Discontinuing unnecessary medications may improve the patient’s overall well-being, but determining which medications may be safely discontinued can be difficult. Since the clinical benefits of statins in the primary and secondary prevention of cardiovascular disease take time to accrue and statins may be associated with an increased risk of adverse events such as gastrointestinal symptoms, myopathy, and musculoskeletal pain, statins have been identified as a reasonable candidate for discontinuation in patients with limited life expectancy. A recent randomized trial compared statin discontinuation vs. continuation in 381 patients (mean age, 74 years) with advanced life-limiting illness on statin therapy for three or more months. All patients included in this trial had an estimated life expectancy of one month to one year and recent functional status deterioration (unrelated to cardiovascular health/status). Most patients (69%) had been taking statins for more than five years, and nearly half of patients (48.8%) had a primary diagnosis of cancer (JAMA Intern Med. 2015 Mar 23 early online).
Although this trial was originally designed to determine the effect of statin discontinuation on survival, this primary outcome was modified to death within 60 days after a prespecified interim analysis observed a longer median survival than initially projected. Median duration of follow-up was 18 weeks, and overall mean survival was 213 days. Comparing statin discontinuation vs. continuation, death within 60 days occurred in 23.8% vs. 20.3% (not significant), and median time to death was 229 days vs. 190 days (not significant). There were also no significant differences in cardiovascular-related events, physical symptoms, statin-specific symptoms, or performance status. Statin discontinuation was associated with an increased total McGill Quality of Life score compared with statin continuation (7.11 vs. 6.85, P = 0.04). Discontinuation of statins was also associated with a per patient cost savings of $3.37 per day, totaling on average $716.46 for the remainder of the patient’s life.
This trial suggests that statin discontinuation may not influence survival or increase the rate of cardiovascular events in patients with advanced life-limiting illness but may be associated with a small improvement in patient quality of life and significant monetary savings.
Alan Ehrlich, MD, is a deputy editor for DynaMed, in Ipswich, Mass., and assistant clinical professor in Family Medicine, University of Massachusetts Medical School in Worcester.
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