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Affiliation(s)
- Nadine E Stephenson
- School of Psychological Science, Faculty of Science, Technology and Engineering, La Trobe University,
| | - Simon F Crowe
- School of Psychological Science, Faculty of Science, Technology and Engineering, La Trobe University,
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Bonnet F, Bénard A, Poulizac P, Afonso M, Maillard A, Salvo F, Berdaï D, Salles N, Rousselot N, Marchi S, Hayes N, Joseph JP. Discontinuing statins or not in the elderly? Study protocol for a randomized controlled trial. Trials 2020; 21:342. [PMID: 32307005 PMCID: PMC7169009 DOI: 10.1186/s13063-020-04259-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 03/15/2020] [Indexed: 12/25/2022] Open
Abstract
Background The risk/benefit ratio of using statins for primary prevention of cardiovascular (CV) events in elderly people has not been established. The main objectives of the present study are to assess the cost-effectiveness of statin cessation and to examine the non-inferiority of statin cessation in terms of mortality in patients aged 75 years and over, treated with statins for primary prevention of CV events. Methods The “Statins in the elderly” (SITE) study is an ongoing 3-year follow-up, open-label comparative multi-centre, randomized clinical trial that is being conducted in two parallel groups in outpatient primary care offices. Participants meeting the following criteria are included: people aged 75 years and older being treated with statins as primary prevention for CV events, who provide informed consent. After randomization, patients in the statin-cessation strategy are instructed to withdraw their treatment. In the comparison strategy, patients continue their statin treatment at the usual dosage. The cost-effectiveness of the statin-cessation strategy compared to continuing statins will be estimated through the incremental cost per quality-adjusted life years (QALYs) gained at 36 months, from the perspective of the French healthcare system. Overall mortality will be the primary clinical endpoint. We assumed that the mortality rate at 3 years will be 15%. The sample size was computed to achieve 90% power in showing the non-inferiority of statin cessation, assuming a non-inferiority margin of 5% of the between-group difference in overall mortality. In total, the SITE study will include 2430 individuals. Discussion There is some debate on the value of statins in people over 75 years old, especially for primary prevention of CV events, due to a lack of evidence of their efficacy in this population, potential compliance-related events, drug-drug interactions and side effects that could impair quality of life. Data from clinical trials guide the initiation of medication therapy for primary or secondary prevention of CV disease but do not define the timing, safety, or risks of discontinuing the agents. The SITE study is one of the first to examine whether treatment cessation is a cost-effective and a safe strategy in people of 75 years and over, formerly treated with statins. Trial registration ClinicalTrials.gov: NCT02547883. Registered on 11 September 2015.
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Affiliation(s)
- Fabrice Bonnet
- CHU de Bordeaux, Service de Médecine Interne et Maladies Infectieuses, Saint-André Hospital, 1 rue Jean Burguet, F-33000, Bordeaux, France. .,ISPED, INSERM U1219, Bordeaux Population Health Research Center, University of Bordeaux, F-33000, Bordeaux, France.
| | - Antoine Bénard
- CHU de Bordeaux, Pôle de Santé Publique, Clinical Epidemiology Unit (USMR), F-33000, Bordeaux, France.,ISPED, INSERM U1219, Bordeaux Population Health Research Center, Team EMOS, UMR 1219, University of Bordeaux, F-33000, Bordeaux, France
| | - Pierre Poulizac
- CHU de Bordeaux, Direction de la Recherche Clinique et de l'Innovation, F-33000, Bordeaux, France
| | - Mélanie Afonso
- Département de Médecine Générale, University of Bordeaux, F-33000, Bordeaux, France
| | - Aline Maillard
- CHU de Bordeaux, Pôle de Santé Publique, Clinical Epidemiology Unit (USMR), F-33000, Bordeaux, France
| | - Francesco Salvo
- ISPED, INSERM U1219, Bordeaux Population Health Research Center, Pharmaco-Epidemiology Team, UMR 1219, University of Bordeaux, F-33000, Bordeaux, France.,CHU de Bordeaux, Service de Pharmacologie Médicale, F-33000, Bordeaux, France
| | - Driss Berdaï
- CHU de Bordeaux, Service de Pharmacologie Médicale, F-33000, Bordeaux, France
| | - Nathalie Salles
- CHU de Bordeaux, Service de Gériatrie, Hôpital Haut-Lévêque, F-33000, Bordeaux, France
| | - Nicolas Rousselot
- Département de Médecine Générale, University of Bordeaux, F-33000, Bordeaux, France
| | - Sébastien Marchi
- CHU de Bordeaux, Direction de la Recherche Clinique et de l'Innovation, F-33000, Bordeaux, France
| | - Nathalie Hayes
- CHU de Bordeaux, Direction de la Recherche Clinique et de l'Innovation, F-33000, Bordeaux, France
| | - Jean-Philippe Joseph
- ISPED, INSERM U1219, Bordeaux Population Health Research Center, University of Bordeaux, F-33000, Bordeaux, France.,Département de Médecine Générale, University of Bordeaux, F-33000, Bordeaux, France
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3
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The impact of statins on physical activity and exercise capacity: an overview of the evidence, mechanisms, and recommendations. Eur J Appl Physiol 2020; 120:1205-1225. [PMID: 32248287 DOI: 10.1007/s00421-020-04360-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Accepted: 03/24/2020] [Indexed: 12/16/2022]
Abstract
PURPOSE Statins are among the most widely prescribed medications worldwide. Considered the 'gold-standard' treatment for cardiovascular disease (CVD), statins inhibit HMG-CoA reductase to ultimately reduce serum LDL-cholesterol levels. Unfortunately, the main adverse event of statin use is the development of muscle-associated problems, referred to as SAMS (statin-associated muscle symptoms). While regular moderate physical activity also decreases CVD risk, there is apprehension that physical activity may induce and/or exacerbate SAMS. While much work has gone into identifying the epidemiology of SAMS, only recent research has focused on the extent to which these muscle symptoms are accompanied by functional declines. The purpose of this review is to provide an overview of possible mechanisms underlying SAMS and summarize current evidence regarding the relationship between statin treatment, physical activity, exercise capacity, and SAMS development. METHODS PubMed and Google Scholar databases were used to search the most relevant and up-to-date peer-reviewed research on the topic. RESULTS The mechanism(s) behind SAMS, including altered mitochondrial metabolism, reduced coenzyme Q10 levels, reduced vitamin D levels, impaired calcium homeostasis, elevated extracellular glutamate, and genetic polymorphisms, still lack consensus and remain up for debate. Our summation of the evidence leads us to suggest that the etiology of SAMS development is likely multifactorial. Our review also demonstrates that there is limited evidence for statins impairing exercise adaptations or reducing exercise capacity for the majority of the investigated populations. CONCLUSION The available evidence indicates that the benefits of engaging in physical activity while on statin medication largely outweigh the risks.
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Viscogliosi G, Donfrancesco C, Lo Noce C, Vanuzzo D, Carle F, Giampaoli S, Palmieri L. Prevalence and Correlates of Statin Underuse for Secondary Prevention of Cardiovascular Disease in Older Adults 65-79 Years of Age: The Italian Health Examination Survey 2008-2012. Rejuvenation Res 2020; 23:394-400. [PMID: 32008438 DOI: 10.1089/rej.2019.2268] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Limited data are available on the prevalence and correlates of statin use for secondary cardiovascular (CV) prevention in the older adult population. We used data of older adults (65-79 years) with established atherosclerotic CV disease from the cross-sectional Italian Health Examination Survey 2008-2012 to address this issue. Lifestyles, CV risk factors, chronic diseases, and therapies were assessed using standardized procedures. A comprehensive geriatric assessment was performed to evaluate cognitive function, disability in basic activities of daily living/instrumental activities of daily living, mobility, and polypharmacy. Multiple regression analyses were performed to identify independent correlates of statin use. A total of 392 participants (mean age 72.1 ± 4.4 years, 61.5% men) were considered for this analysis. Coronary heart disease was identified in 67.1% of participants, cerebrovascular disease in 23.5%, and peripheral artery disease (PAD) in 18.1%. One hundred ninety (48.5%) were statin users. By multiple regression analysis, functional disability (odds ratio [OR] = 0.81; 95% confidence interval [CI] = 0.71-0.92; p = 0.002), cognitive impairment (OR = 0.87; 95% CI = 0.78-0.98; p = 0.018), and polypharmacy (OR = 0.86; 95% CI = 0.75-0.98; p = 0.035) predicted statin nonuse, whereas having hypertension (OR = 1.19; 95% CI = 1.05-1.34; p = 0.005), diabetes mellitus (OR = 1.14; 95% CI = 1.03-1.27; p = 0.013), or a previous myocardial revascularization (OR = 1.31; 95% CI = 1.16-1.48; p < 0.001) predicted statin use. Significant interaction terms were observed between cerebrovascular disease, PAD, cognitive impairment, and disability in predicting statin nonuse. Statin underuse in older adults aged 65-79 years with CV disease, and thus suboptimal secondary CV prevention, is highly prevalent despite current guidelines and recommendations. Common geriatric conditions are associated with statin nonuse. Such results support the need for improving the awareness of statin treatment for secondary CV prevention.
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Affiliation(s)
- Giovanni Viscogliosi
- Department of Cardiovascular, Dysmetabolic and Ageing-Associated Diseases, National Institute of Health, Rome, Italy.,Department of Epidemiology, Centre of Epidemiology and Biostatistics, Polytechnic University of Marche, Ancona, Italy
| | - Chiara Donfrancesco
- Department of Cardiovascular, Dysmetabolic and Ageing-Associated Diseases, National Institute of Health, Rome, Italy
| | - Cinzia Lo Noce
- Department of Cardiovascular, Dysmetabolic and Ageing-Associated Diseases, National Institute of Health, Rome, Italy
| | - Diego Vanuzzo
- Department of Cardiology, National Association Hospital Cardiologists, Florence, Italy
| | - Flavia Carle
- Department of Epidemiology, Centre of Epidemiology and Biostatistics, Polytechnic University of Marche, Ancona, Italy
| | - Simona Giampaoli
- Department of Cardiovascular, Dysmetabolic and Ageing-Associated Diseases, National Institute of Health, Rome, Italy
| | - Luigi Palmieri
- Department of Cardiovascular, Dysmetabolic and Ageing-Associated Diseases, National Institute of Health, Rome, Italy
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The Safety and Tolerability of Statin Therapy in Primary Prevention in Older Adults: A Systematic Review and Meta-analysis. Drugs Aging 2020; 37:175-185. [DOI: 10.1007/s40266-019-00736-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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The 2018 Cholesterol Management Guidelines: Topics in Secondary ASCVD Prevention Clinicians Need to Know. Curr Atheroscler Rep 2019; 21:20. [PMID: 30941517 DOI: 10.1007/s11883-019-0784-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW The 2018 ACC/AHA Multisociety blood cholesterol guidelines provide updated recommendations based on contemporary evidence on the management of serum cholesterol for the prevention of atherosclerotic cardiovascular disease (ASCVD) events. This review discusses clinically important topics in the new guidelines related to secondary ASCVD prevention. RECENT FINDINGS Since the 2013 ACC/AHA blood cholesterol guidelines, several large randomized control trials involving ezetimibe and proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors (evolocumab and alirocumab) have been published. The trials provided evidence that these non-statin, LDL-cholesterol lowering agents are efficacious in reducing risk for ASCVD events in patients with clinical ASCVD. The 2018 guidelines incorporate these new findings into updated clinical recommendations on therapeutic strategies related to the use of ezetimibe and PCSK9 inhibitors. The guidelines also recommend risk stratification of secondary prevention patients to identify those at very high-risk of ASCVD events as these patients would derive the most absolute risk reduction from the addition of non-statin therapies. While high-intensity statins remain the first-line treatment to prevent recurrent ASCVD events in secondary prevention patients, ezetimibe and PCSK9 inhibitors are evidence-based non-statin agents that can be used when residual on top of maximally tolerated statin therapy in patients deemed to be at very-high risk of recurrent ASCVD events.
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Nishtala PS, Gnjidic D, Chyou T, Hilmer SN. Discontinuation of statins in a population of older New Zealanders with limited life expectancy. Intern Med J 2016; 46:493-6. [DOI: 10.1111/imj.13024] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2015] [Revised: 10/03/2015] [Accepted: 10/11/2015] [Indexed: 12/21/2022]
Affiliation(s)
- P. S. Nishtala
- School of Pharmacy; University of Otago; Dunedin New Zealand
| | - D. Gnjidic
- Faculty of Pharmacy; University of Sydney; Sydney New South Wales Australia
| | - T. Chyou
- School of Pharmacy; University of Otago; Dunedin New Zealand
| | - S. N. Hilmer
- Sydney Medical School, Royal North Shore Hospital, and Kolling Institute of Medical Research; University of Sydney; Sydney New South Wales Australia
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8
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Pavanello C, Mombelli G. Considering gender in prescribing statins: what do physicians need to know? ACTA ACUST UNITED AC 2015. [DOI: 10.2217/clp.15.39] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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9
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Joseph JP, Afonso M, Berdaï D, Salles N, Bénard A, Gay B, Bonnet F. [Benefits and risks for primary prevention with statins in the elderly]. Presse Med 2015; 44:1219-25. [PMID: 26585744 DOI: 10.1016/j.lpm.2015.09.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Revised: 07/29/2015] [Accepted: 09/07/2015] [Indexed: 01/06/2023] Open
Abstract
CONTEXT Statins in primary prevention before 75 years old reduce cardiovascular events from 20 to 30% and mortality from 10% with acceptable side effects. We investigated whether these results persisted for patients aged 75 and older taking statin. METHOD Methodic review of large randomized clinical trials and meta-analyzes that included patients 75 years and older treated with statins in primary prevention. RESULTS Since the 1990s, a score of randomized controlled trials studying statins versus placebo in primary prevention were published and studied in meta-analyses. Exclusion criteria, including persons older than 70 years, are often restrictive. The impact on all-cause mortality in the four main studies and meta-analyses in over 75 years has not been demonstrated. On the other hand, a recent meta-analyses of observational studies including subjects between 70 and 89 years treated with statins found that low total cholesterol was associated with a moderate decrease in cardiovascular mortality, with no decrease in all-cause mortality. Moreover, in a common context of comorbidities in this age group, statins may be responsible for many adverse effects, drug interactions and impaired quality of life. CONCLUSION Given the lack of formal evidence of effectiveness in terms of all-cause mortality and a high level of adverse effects, the benefit/risk of primary prevention with statins is not established in the elderly. The economic weight of statin prescriptions and their possible impact on quality of life justify an economic analysis of discontinuing statin therapy for people 75 years and older.
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Affiliation(s)
- Jean-Philippe Joseph
- Université de Bordeaux, département de médecine générale, 146, rue Léo-Saignat, 33076 Bordeaux cedex, France.
| | - Mélanie Afonso
- Université de Bordeaux, département de médecine générale, 146, rue Léo-Saignat, 33076 Bordeaux cedex, France
| | - Driss Berdaï
- CHU de Bordeaux, service de pharmacologie médicale, place Amélie-Raba-Léon, 33076 Bordeaux cedex, France
| | - Nathalie Salles
- CHU de Bordeaux, hôpital Haut-Lévèque, département de gériatrie, 33604 Pessac cedex, France
| | - Antoine Bénard
- CHU de Bordeaux, USMR, place Amélie-Raba-Léon, 33076 Bordeaux cedex, France
| | - Bernard Gay
- Université de Bordeaux, département de médecine générale, 146, rue Léo-Saignat, 33076 Bordeaux cedex, France
| | - Fabrice Bonnet
- CHU de Bordeaux, hôpital Saint-André, service de médecine interne et maladies infectieuses, 33000 Bordeaux, France
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10
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Hamilton-Craig I, Colquhoun D, Kostner K, Woodhouse S, d’Emden M. Lipid-modifying therapy in the elderly. Vasc Health Risk Manag 2015; 11:251-63. [PMID: 25999729 PMCID: PMC4437602 DOI: 10.2147/vhrm.s40474] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Cardiovascular disease (CVD) mortality and morbidity increases with increasing age, largely as a result of increased lifetime exposure as well as increased prevalence of CVD risk factors. Hospitalization for CVD increases by a factor of over 18× for those aged 85+ years versus those aged <30 years. In spite of this, life expectancy continues to increase, and in Australia for people reaching the age of 65 years, it is now 84 years in men and 87 years in women. The number of people for whom lipid management is potentially indicated therefore increases with aging. This is especially the case for secondary prevention and for people aged 65-75 years for whom there is also evidence of benefit from primary prevention. Many people in this age group are not treated with lipid-lowering drugs, however. Even those with CVD may be suboptimally treated, with one study showing treatment rates to fall from ~60% in those aged <50 years to <15% for those aged 85+ years. Treatment of the most elderly patient groups remains controversial partly from the lack of randomized trial intervention data and partly from the potential for adverse effects of lipid therapy. There are many complex issues involved in the decision to introduce effective lipid-lowering therapy and, unfortunately, in many instances there is not adequate data to make evidence-based decisions regarding management. This review summarizes the current state of knowledge of the management of lipid disorders in the elderly and proposes guidelines for management.
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Affiliation(s)
- Ian Hamilton-Craig
- Griffith University School of Medicine, Griffith Health Institute, Gold Coast, QLD, Australia
- Flinders University School of Medicine, Adelaide, SA, Australia
| | - David Colquhoun
- Wesley Medical Centre, Auchenflower, QLD, Australia
- University of Queensland, Brisbane, QLD, Australia
| | - Karam Kostner
- University of Queensland, Brisbane, QLD, Australia
- Department of Cardiology, Mater Hospital, Woolloongabba, QLD, Australia
| | - Stan Woodhouse
- University of Queensland, Brisbane, QLD, Australia
- Taylor Medical Centre, Woolloongabba, QLD, Australia
| | - Michael d’Emden
- University of Queensland, Brisbane, QLD, Australia
- Department of Endocrinology, Royal Brisbane Hospital, Herston, QLD, Australia
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11
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Abstract
Approximately 95% of statin-treated patients tolerate this form of cholesterol management without any adverse effects. However, given their efficacy in reducing low density lipoproteins and cardiovascular events large numbers of patients are selected for statin therapy. Therefore muscle complications are, in fact, quite common. Limited understanding of the underlying pathophysiology has hampered physicians' ability to identify patients at risk for developing statin myotoxicity. A growing number of published case reports/series have implicated statins in the exacerbation of both acquired and genetic myopathies. A clinical management algorithm is presented which outlines a variety of co-morbidities which can potentiate the adverse effects of statins on muscle. In addition, a rational approach to the selection of those patients most likely to benefit from skeletal muscle biopsy is discussed. Ongoing work will define the extent to which statin-intolerant patients represent carriers of recessive metabolic myopathies or pre-symptomatic acquired myopathies. The expanding importance of pharmacogenomics will undoubtedly be realized in the field of statin myopathy research within the next few years. Such critical information is needed to establish more definitive management and diagnostic strategies.
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12
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[Psychotic Acute Episode and Rhabdomyolysis after Lovastatin Ingestion]. ACTA ACUST UNITED AC 2014; 41:672-9. [PMID: 26572120 DOI: 10.1016/s0034-7450(14)60037-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2012] [Accepted: 05/15/2012] [Indexed: 01/15/2023]
Abstract
INTRODUCTION Statins are the most prescribed drugs worldwide given the benefit and security they offer. However, they can cause severe neurological, gastrointestinal, renal and muscular side effects. OBJECTIVE To describe the clinical course of a female patient with adverse drug reaction to Lovastatin. METHODS Case report and literature review. RESULTS 52-year old woman with sudden psychosis and rhabdomyolysis secondary to Lovastatin and ending after the drug suspension. The causal relationship was corroborated with a score of 6 (probable ADR) on Naranjo's Scale. CONCLUSIONS The simultaneous manifestation of psychosis and rhabdomiolysis represents an atypical and unique case following Lovastatin ingestion.
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Abstract
Statins, inhibitors of the hydroxymethylglutaryl-CoA (HMG-CoA) reductase enzyme, are molecules of fungal origin. By inhibiting a key step in the sterol biosynthetic pathway statins are powerful cholesterol lowering medications and have provided outstanding contributions to the prevention of cardiovascular disease. Their detection in mycetes traces back to close to 40 years ago: there were, originally, widely opposing views on their therapeutic potential. From then on, intensive pharmaceutical development has led to the final availability in the clinic of seven statin molecules, characterized by differences in bioavailability, lipo/hydrophilicity, cytochrome P-450 mediated metabolism and cellular transport mechanisms. These differences are reflected in their relative power (mg LDL-cholesterol reduction per mg dose) and possibly in parenchymal or muscular toxicities. The impact of the antagonism of statins on a crucial step of intermediary metabolism leads, in fact, both to a reduction of cholesterol biosynthesis as well as to additional pharmacodynamic (so called "pleiotropic") effects. In the face of an extraordinary clinical success, the emergence of some side effects, e.g. raised incidence of diabetes and cataracts as well as frequent muscular side effects, have led to increasing concern by physicians. However, also in view of the present relatively low cost of these drugs, their impact on daily therapy of vascular patients is unlikely to change.
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Affiliation(s)
- Cesare R Sirtori
- Center of Dyslipidemias, Niguarda Hospital, Italy; Professor of Clinical Pharmacology, Università degli Studi di Milano, Italy.
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14
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Prescribing statins for cardiovascular disease prevention in the old: an absence of evidence and an absence of guidelines. Heart Lung Circ 2014; 23:619-24. [PMID: 24704467 DOI: 10.1016/j.hlc.2014.03.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2013] [Revised: 03/01/2014] [Accepted: 03/04/2014] [Indexed: 12/31/2022]
Abstract
Australia's oldest old are potentially being harmed by the under- and over- use of statins. Variations in prescription of statins are in part due to the vacuum of clinical research trial evidence and paucity of contemporary guidelines that are needed to address the use of lipid lowering therapy in the oldest old. There are a few randomised placebo-controlled trials that recruited an older population. Therefore evidence of statins efficacy in the oldest old is based on an extrapolation of results from those studies. The extensive exclusion criteria of those studies, the relative youth of the study participants, the low levels of comorbidity and functional impairment limit the external validity and the generalisability of the findings. Current guidelines are silent or generally non-specific about statin therapy for the oldest old deferring decisions to individual medical practitioners. Life expectancy, time to benefit, functional status and medication related adverse events, polypharmacy, adherence to treatment are factors that need to be considered when forming appropriate guidelines for statin prescription in the very old. Well-designed clinical trials that account for the heterogeneity of this population are needed. While waiting for this research evidence better clinical guidelines are needed to address this issue.
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Abstract
OBJECTIVES Use of high-dose statin therapy (HDST) in patients with stroke became standard clinical practice after the Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL) study, in which the mean age of the study population was approximately 63 years. Little data are available on the adverse effects of statins when used in high doses in adults older than 65 years. The objective of this study was to assess the magnitude of adverse effects of HDST in geriatric patients. METHODS This single-center, retrospective, case-control study was conducted at Upstate Medical University, Syracuse, New York. All patients older than 65 years admitted between 2008 and 2011 to the hospital's Upstate Stroke Center with acute stroke were eligible. Electronic medical records of 200 eligible patients were reviewed to collect demographic, clinical, and laboratory data. Patients on HDST (cases) were compared with those on low doses (controls) using the χ, Fisher exact (two-sided), and Student t tests. RESULTS One hundred cases (mean age 80.5 ± 7.7 years) were compared with 100 controls (mean age 78.9 ± 6.4 years). Sixty-seven percent were taking simvastatin. Ninety percent of the cases compared with 81% of the controls had ischemic stroke. The prevalence of elevated alanine aminotransferase (13%) and myositis (4%) was significantly higher in the cases than in the controls. Fourteen percent of the cases reported myalgias, 9% had nausea, and 6% had diarrhea. Seventy-three cases had low-density lipoprotein levels <100 mg% and 41% of the cases had mean glycated hemoglobin levels ≥ 6.5%. CONCLUSIONS The use of HDST in older adult patients with acute stroke is associated with a significantly increased burden of liver enzyme elevation and myalgias.
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Atorvastatin 10 mg plus ezetimibe versus titration to atorvastatin 40 mg: attainment of European and Canadian guideline lipid targets in high-risk subjects ≥65 years. Lipids Health Dis 2014; 13:13. [PMID: 24411003 PMCID: PMC3901347 DOI: 10.1186/1476-511x-13-13] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2013] [Accepted: 12/11/2013] [Indexed: 01/02/2023] Open
Abstract
Background Few clinical studies have focused on the efficacy of lipid-lowering therapies in patients ≥65 years. Methods After stabilization on atorvastatin 10 mg, hypercholesterolemic subjects ≥65 years at high/very high risk for CHD and not at LDL-C <1.81 mmol/L (with atherosclerotic vascular disease [AVD]) or <2.59 mmol/L (without AVD) were randomized to ezetimibe 10 mg plus atorvastatin 10 mg or uptitration to atorvastatin 20 mg (6 weeks) followed by uptitration to 40 mg (additional 6 weeks). A post-hoc analysis compared between-group differences in percent attainment of individual and combined LDL-C, non-HDL-C and Apo B targets based on recommendations from 2012 European and Canadian Cardiovascular Society (CCS) guidelines for dyslipidemia treatment. Results Atorvastatin 10 mg plus ezetimibe produced significantly greater attainment of LDL-C, non-HDL-C, and Apo B individual and dual/triple targets vs. atorvastatin 20 mg for the entire cohort and very high-risk groups at 6 weeks. After 12 weeks, very high-risk subjects maintained significantly greater achievement of LDL-C <1.8 mmol/L (47% vs. 35%), non-HDL-C <2.6 mmol/L (63% vs. 53%) and Apo B <0.8 g/L (47% vs. 38%) single targets and dual/triple targets with atorvastatin 10 mg plus ezetimibe vs. atorvastatin 40 mg, while attainment of European target for high-risk subjects was generally similar for both treatments. Achievement of Canadian targets was significantly greater with combination therapy vs. atorvastatin 20 mg (6 weeks) or atorvastatin 40 mg (12 weeks). Conclusions Atorvastatin 10 mg plus ezetimibe provided more effective treatment than uptitration to atorvastatin 20/40 mg for attainment of most European and Canadian guideline-recommended lipid targets in older at-risk patients. Trial registration ClinicalTrials.gov identifier
NCT00418834.
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Abstract
Statins are an established class of drugs with proven efficacy in cardiovascular risk reduction. The concern over statin safety was first raised with the revelation of myopathy and rhabdomyolysis with the use of now withdrawn cerivastatin. Enhanced understanding of the mechanisms behind adverse effects of statins including an insight into the pharmacokinetic properties have minimised fear of statin use among clinicians. Studies reveal that occurrence of myopathy and rhabdomyolysis are rare 1/100000 patient-years. The risk of myopathy/rhabdomyolysis varies between statins due to varying pharmacokinetic profiles. This explains the differing abilities of statins to adverse effects and drug interaction potentials that precipitate adverse effects. Higher dose of rosuvastatin (80 mg/day) was associated with proteinuria and hematuria while lower doses were devoid of such effects. Awareness of drugs interacting with statins and knowledge of certain combinations such as statin and fibrates together with monitoring of altered creatine kinase activity may greatly minimise associated adverse effects. Statins also asymptomatically raise levels of hepatic transaminases but are not correlated with hepatotoxicity. Statins are safe and well tolerated including more recent potent statins such as, rosuvastatin. The benefits of intensive statin use in cardiovascular risk reduction greatly outweigh risks. The present review discusses underlying causes of statin-associated adverse effects including management in high risk groups.
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Affiliation(s)
- Debasish Maji
- Division of Cardiology, Department of Medicine, Vivekanand Institute of Medical Sciences, Kolkata, India
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18
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Wallach Kildemoes H, Vass M, Hendriksen C, Andersen M. Statin utilization according to indication and age: a Danish cohort study on changing prescribing and purchasing behaviour. Health Policy 2012; 108:216-27. [PMID: 22975117 DOI: 10.1016/j.healthpol.2012.08.008] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2012] [Revised: 05/30/2012] [Accepted: 08/08/2012] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Introduced to reduce mortality after myocardial infarction (MI), statins are now recommended for a range of other conditions, including asymptomatic individuals without cardiovascular disease or diabetes. The aim was to describe trends in Danish statin utilization according to indication and age during 1996-2009, and to analyse changing prescribing and purchasing behaviour during time intervals (driver periods) a priori defined by potential influential factors. METHODS A nationwide cohort (N=4,998,580) was followed in Danish individual-level registries. Based on a hierarchy of register markers of indications for statin prescribing, we analysed incidence and prevalence of use by age and indication (age ≥ 40). Applying Poisson regression, we calculated Incidence Rate Ratios (IRR) of statin treatment for the last year of each driver period, applying the first year as reference. RESULTS Treatment prevalence increased from 7/1000 to 187/1000, representing a shift towards lower-level indications and increased relatively more in individuals aged 75+. While treatment prevalence in MI-patients reached 780/1000, asymptomatic individuals represented 50% of incident statin-users in 2009. A marked increase in incidence of statin use occurred during 1999-2003 (IRR=3.05) across all indications, followed by a more moderate rise during 2003-2006 (IRR=1.29) and 2006-2008 (IRR=1.15) - most marked increases in asymptomatic individuals. A sudden decrease was observed in 2009 (IRR=0.82) for all indications and ages. CONCLUSION While patent expiry and lower prices most likely boosted the general increase in statin utilization, the gradually altered indication and age pattern seems to be driven by guidelines, influencing both reimbursement rules and general healthcare policies. A media debate on statin side effects may have modified the general attitudes.
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19
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Rallidis LS, Fountoulaki K, Anastasiou-Nana M. Managing the underestimated risk of statin-associated myopathy. Int J Cardiol 2012; 159:169-76. [DOI: 10.1016/j.ijcard.2011.07.048] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2011] [Revised: 07/07/2011] [Accepted: 07/10/2011] [Indexed: 12/20/2022]
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20
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Najafian B, Franklin DB, Fogo AB. Acute renal failure and myalgia in a transplant patient. J Am Soc Nephrol 2007; 18:2870-4. [PMID: 17942960 DOI: 10.1681/asn.2007020158] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
A 64-yr-old man with kidney transplant for ESRD as a result of diabetic nephropathy presented with acute renal failure, weakness, myalgia, and pigmented urine. His medications included mycophenolate, cyclosporine, prednisone, furosemide, diltiazem, aspirin, simvastatin, an angiotensin receptor blocker, and insulin. A renal biopsy was performed. Pathologic findings and differential diagnosis are discussed, and the literature is reviewed.
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Affiliation(s)
- Behzad Najafian
- Department of Pathology, Vanderbilt University Medical Center, Nashville, Tennessee 37232-2561, USA
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21
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Roberts CGP, Guallar E, Rodriguez A. Efficacy and safety of statin monotherapy in older adults: a meta-analysis. J Gerontol A Biol Sci Med Sci 2007; 62:879-87. [PMID: 17702880 DOI: 10.1093/gerona/62.8.879] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Statin therapy significantly reduces cardiovascular events. Older patients, however, are less likely to be prescribed statins than younger patients due to concern over lack of indication, lower predictive value of cholesterol levels, and increased risk of adverse events. To determine the effect of statins on all-cause mortality and on major cardiovascular events, including stroke, we performed a meta-analysis of statin trials that included older adult participants. METHODS Mortality, cardiovascular events, and adverse event outcomes were extracted from published randomized, placebo-controlled clinical trials of persons aged 60 years and older. RESULTS Data on 51,351 patients were evaluated. Statins reduced all-cause mortality by 15% (95% confidence interval, 7%-22%), coronary heart disease (CHD) death by 23% (15%-29%), fatal or nonfatal myocardial infarction (MI) by 26% (22%-30%), and fatal or nonfatal stroke by 24% (10%-35%). The relative risk of cancer comparing statins to placebo was 1.06 (0.95-1.18). Adverse event data were not consistently reported. CONCLUSIONS Statin therapy significantly reduced all-cause and CHD mortality, as well as risk of stroke and MI. Statin therapy should be offered to older patients at high risk of atherosclerotic disease events.
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Affiliation(s)
- Caroline G P Roberts
- Division of Endocrinology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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22
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Agostini JV, Tinetti ME, Han L, McAvay G, Foody JM, Concato J. Effects of Statin Use on Muscle Strength, Cognition, and Depressive Symptoms in Older Adults. J Am Geriatr Soc 2007; 55:420-5. [PMID: 17341246 DOI: 10.1111/j.1532-5415.2007.01071.x] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVES To determine the relationship between hydroxymethyl glutaryl coenzyme A reductase inhibitor (statin) use and proximal muscle strength, cognition, and depression in older adults. DESIGN Observational cohort study. SETTING Outpatient primary care clinics. PARTICIPANTS Seven hundred fifty-six community-dwelling veterans aged 65 and older. MEASUREMENTS Timed chair stands (a measure of proximal muscle strength), Trail Making Test Part B (a measure of cognition), and the Center for Epidemiologic Studies Depression Scale score were measured at baseline and 1-year follow-up. Participants were assessed for statin prescriptions (and indications for or contraindications to their use), concomitant medication use, comorbidities, and other potential confounders. RESULTS Statin users (n=315) took a mean 6.6 medications, versus 4.6 for nonusers (n=441), and had a median duration of statin use of 727 days. Statin users were more likely to be white and had (as expected) more cardiac, cerebrovascular, and peripheral vascular disease. Based on multivariable models adjusting for pertinent covariates, statin users performed modestly better than nonusers for timed chair stands (-0.5 seconds; P=.04), Trail Making Test Part B (-7.7 seconds; P=.08), and depression scores (-0.2 points; P=.49) at follow-up. Of potentially high-risk participants (based on age, comorbidity, and number of medications), statin users also showed similar 1-year changes as nonusers, although worsened depression scores were found in those with greater comorbidity (+0.88 points; P=.10). CONCLUSION Older, community-dwelling male participants taking maintenance statin therapy had similar outcomes to those of nonusers in tests of muscle strength, cognition, and depression, but further examination of benefits and harms in different subgroups is warranted.
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Affiliation(s)
- Joseph V Agostini
- Clinical Epidemiology Research Center, VA Connecticut Healthcare System, West Haven, Connecticut 06516, USA.
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23
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Deedwania P, Stone PH, Bairey Merz CN, Cosin-Aguilar J, Koylan N, Luo D, Ouyang P, Piotrowicz R, Schenck-Gustafsson K, Sellier P, Stein JH, Thompson PL, Tzivoni D. Effects of Intensive Versus Moderate Lipid-Lowering Therapy on Myocardial Ischemia in Older Patients With Coronary Heart Disease. Circulation 2007; 115:700-7. [PMID: 17283260 DOI: 10.1161/circulationaha.106.654756] [Citation(s) in RCA: 154] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Clinical trials have demonstrated that, compared with placebo, intensive statin therapy reduces ischemia in patients with acute coronary syndromes and in patients with stable coronary artery disease. However, no studies to date have assessed intensive versus moderate statin therapy in older patients with stable coronary syndromes.
Methods and Results—
A total of 893 ambulatory coronary artery disease patients (30% women) 65 to 85 years of age with ≥1 episode of myocardial ischemia that lasted ≥3 minutes during 48-hour ambulatory ECG at screening were randomized to atorvastatin 80 mg/d or pravastatin 40 mg/d and followed up for 12 months. The primary efficacy parameter (absolute change from baseline in total duration of ischemia at month 12) was significantly reduced in both groups at month 3 and month 12 (both
P
<0.001 for each treatment group) with no significant difference between the treatment groups. Atorvastatin-treated patients experienced greater low-density lipoprotein cholesterol reductions than did pravastatin-treated patients, a trend toward fewer major acute cardiovascular events (hazard ratio, 0.71; 95% confidence interval, 0.46, 1.09;
P
=0.114), and a significantly greater reduction in all-cause death (hazard ratio, 0.33; 95% confidence interval, 0.13, 0.83;
P
=0.014).
Conclusions—
Compared with moderate pravastatin therapy, intensive atorvastatin therapy was associated with reductions in cholesterol, major acute cardiovascular events, and death in addition to the reductions in ischemia observed with both therapies. The contrast between the therapies’ differing efficacy for major acute cardiovascular events and death and their nonsignificant difference in efficacy for reduction of ischemia suggests that low-density lipoprotein cholesterol–lowering thresholds for ischemia and major acute cardiovascular events may differ. The Study Assessing Goals in the Elderly (SAGE) demonstrates that older men and women with coronary artery disease benefit from intensive statin therapy.
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Abstract
Statins are portrayed as harmless drugs that almost everyone would benefit from, but little is known about the side effects at the high doses now being suggested
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Antons KA, Williams CD, Baker SK, Phillips PS. Clinical perspectives of statin-induced rhabdomyolysis. Am J Med 2006; 119:400-9. [PMID: 16651050 DOI: 10.1016/j.amjmed.2006.02.007] [Citation(s) in RCA: 137] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2005] [Revised: 01/26/2006] [Accepted: 02/08/2006] [Indexed: 11/30/2022]
Abstract
Fear of muscle toxicity remains a major reason that patients with hyperlipidemia are undertreated. Recent evaluations of statin-induced rhabdomyolysis offer new insights on the clinical management of both muscle symptoms and hyperlipidemia after rhabdomyolysis. The incidence of statin-induced rhabdomyolysis is higher in practice than in controlled trials in which high-risk subjects are excluded. Accepted risks include age; renal, hepatic, and thyroid dysfunction; and hypertriglyceridemia. New findings suggest that exercise, Asian race, and perioperative status also may increase the risk of statin muscle toxicity. The proposed causes and the relationship of drug levels to statin rhabdomyolysis are briefly reviewed along with the problems with the pharmacokinetic theory. Data suggesting that patients with certain metabolic abnormalities are predisposed to statin rhabdomyolysis are presented. The evaluation and treatment of patients' muscle symptoms and hyperlipidemia after statin rhabdomyolysis are presented. Patients whose symptoms are related to other disorders need to be identified. Lipid management of those whose symptoms are statin-related is reviewed including treatment suggestions.
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Affiliation(s)
- Kenneth A Antons
- Scripps Mercy Clinical Research Center, Scripps Mercy Hospital, San Diego, Calif 92103, USA
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Abstract
The 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors, or statin drugs, have been studied in numerous controlled human research trials involving hundreds of thousands of study participants. Statins have been prescribed for millions of patients. Based on this vast research and clinical experience, statins have been shown to improve lipid blood levels and reduce atherosclerotic coronary artery disease (CAD) risk, resulting in reduced CAD morbidity and mortality, and in several studies, reduced overall ("all-cause") mortality. From a safety perspective, both research trial evidence and clinical practice experience have demonstrated that statins are generally well tolerated. However, as with all pharmaceuticals, safety considerations exist with both monotherapy and combination statin therapy, mainly involving potential adverse effects on muscle, liver, kidney, and the nervous system. The evidence supporting statin-related potential adverse experiences on these organ systems is sometimes strong and based on clear clinical trial evidence (such as the increased risk of muscle enzyme elevation with higher statin doses). The evidence is at other times more speculative, being based on case reports and inconclusive clinical trial data (such as possible favorable or unfavorable effects of statins on cognition). Because the use of statins is so widespread, it is useful for the clinician to understand statin safety issues and the level of available evidence supporting the contention that various adverse effects are caused by statins. This review presents an assessment of statin safety based on an overview of the current statin safety data and their clinical implications.
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Affiliation(s)
- Harold Bays
- Louisville Metabolic and Atherosclerosis Research Center, Louisville, Kentucky 40213, USA.
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