Deprescribing statins

If you found out that a medication you had been taking for years was much less effective than previously advertised, would you keep taking it?

An estimated 20 to 30 percent of Americans over the age of 45 takes a statin for high cholesterol, a history of heart attack or stroke, or to prevent a cardiovascular event. Once a patient starts a statin, provided that they don't experience side effects, they usually continue taking it for life. The medication lists of nursing home residents almost invariably include statins. Statin prescribing has been overwhelmingly positive for population health; a recent study credited them with closing the gap in cardiovascular risk factors between middle-aged adults with obesity and those with normal weight. Ultimately, though, an individual reaches a point where a statin is likely to cause more harm than benefit, even if the harm is having to take one extra medication that costs as little as 30 cents per day.

An expert panel at Deprescribing.org, which previously published evidence-based guidelines on discontinuing proton pump inhibitors, antihyperglycemics, and antipsychotics, among others, recently added statins to its deprescribing guidelines. A synopsis of the guideline is available as an algorithm on their website. In adults over age 65, several factors may prompt a conversation about discontinuing statins: frailty, pill burden, functional limitations, cognitive impairment, complex care needs, and advanced illness (e.g., cancer). A person with a terminal illness who isn't expected to live for more than a year is an ideal candidate for stopping a statin, but some patients with longer life expectancies may reasonably decide to discontinue them based on their personal goals and the value they assign to preventing future cardiovascular events.

None of this should be particularly controversial, but I would have gone farther if I had been on the guideline committee. The replacement of the Pooled Cohort Equations with the PREVENT calculator has resulted in many adults now having a significantly lower estimated risk of cardiovascular events. That should have prompted a reconsideration of statin use for patients whose new risk estimate fell under the threshold for statin initiation. Instead, as I discussed in a Medscape commentary, the American College of Cardiology / American Heart Association simply moved the goalposts, recommending statin initiation (and continuation) at lower thresholds:

Although these changes make it unnecessary to have potentially awkward conversations with patients about why they may no longer need medications that they’ve been taking for years, moving the goalposts is not warranted by primary prevention RCTs, which generally enrolled persons with 10% or greater 10-year risk. Even if one assumes that the relative benefits are the same, patients deserve to be informed about their lower risk estimates so that they can weigh the higher numbers needed to treat before deciding if starting or continuing statin therapy is worthwhile.

I went on to make a deprescribing recommendation that I expect many cardiologists and primary care physicians will disagree with:

Patients at lower risk [based on the PREVENT calculator], particularly less than 5%, should be offered the option of discontinuing statins, keeping in mind the “risk enhancers” listed in the ACC/AHA guideline, which may suggest that the calculated value underestimates their true risk.

Statins haven't become less effective in relative terms, but changes in risk estimates mean that the absolute risk reductions in cardiovascular events and deaths that patients can expect from these drugs are smaller than they were before. And that means that in some cases, deprescribing statins may be a clinically appropriate action.

source http://commonsensemd.blogspot.com/2026/07/deprescribing-statins.html