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Donald W. Reynolds Foundation, the Arizona Geriatric Education Center, and the Arizona Center on Aging
A Resource for Providers
Hyperlipidemia in Older Adults: To Treat or Not to Treat?
Carol L. Howe, MD, MLS, College of Medicine, University of Arizona Barry D. Weiss, MD, College of Medicine, University of Arizona Treatment of hyperlipidemia has well-known benefits for or more past episodes of myocardial ischemia. They lowering the rate of acute cardiac events and other were randomized to intensive (atorvastatin 80 mg/day) complications of atherosclerosis. Accordingly, current vs moderate (pravastatin 40 mg/day) lipid-lowering practice guidelines, including those from the National therapy. After one year, intensive therapy reduced Cholesterol Education Program (NCEP), recommend cardiac events by 28%. treating hyperlipidemia with diet and medication to reduce Based on these two studies, and many others which elevated lipids. The NCEP guidelines provide no upper included older adults (Table 1), most experts feel that age limit for treating hyperlipidemia. Yet, it is well older patients are likely to benefit from lipid lowering established that for some older individuals, low lipid levels therapy, regardless of age. In fact, many researchers are associated with poor outcomes, not improved outcomes. have concluded that older adults have a greater reduction Thus, there has been controversy about whether to treat in coronary events and death than their younger hyperlipidemia in all older people. This controversy plays counterparts if they take statins – though, as noted, they out in daily practice, where older patients are less likely are less likely than younger people to receive a than younger patients to be treated with statins – with a prescription for a statin. 6% less chance of receiving statins for every year of age
over 65 – even though people over 65 are more likely Are Any Statins Better Than Others?
than younger people to die from cardiovascular disease. This issue of Elder Care reviews the approach to lipid-
The most common statin side effect is myopathy, which can
lowering therapy for older adults in general, and for range from mild muscle pain to rhabdomyolysis. Older age; small body size; preexisting liver, renal, or endocrine disease; multiple medications; and high statin Lipid-Lowering Therapy for Older Adults
doses all are risks for myopathy. Fluvastatin and pravastatin have the lowest risk for myopathy (Figure 1),
Most studies of lipid-lowering therapy involved statins. Two but they are the least potent statins and often need higher
focused exclusively on older adults.
doses to be effective – thus increasing risk. Rosuvastatin also carries a low risk for myopathy and, as the most One of the two studies was the PROspective Study of potent statin available, can often be given in very low Pravastatin in Elderly individuals at Risk of vascular doses, making it a good option for treating older adults. disease (PROSPER). PROSPER randomized nearly 6,000 people, aged 70-82 with risk factors for, or a history of, The risk of myopathy is also increased when statins are vascular disease, to receive 40 mg/day of pravastin or a given with other medications associated with myopathy—placebo. In comparison to placebo, by the end of the 3- such as gemfibrozil or, in the case of atorvastatin, year study pravastatin therapy lowered the rate of lovastatin, and simvastatin--all metabolized by the same coronary heart disease deaths by 23%. cytochrome enzyme (CYP3A4)—when they are given with CYP3A4 inhibitors such as amiodarone, azole antifungals, The other study, Study Assessing Goals in the Elderly, (SAGE), enrolled 893 people aged 65-85 who had one diltiazem, verapamil, macrolides, or grapefruit juice. TIPS FOR TREATING HYPERLIPIDEMIA IN OLDER ADULTS
 Give statins to older adults with hyperlipidemia in most cases. Research shows that most older adults with hyperlipi- demia would benefit from statins, but providers often don’t prescribe them.  Select a statin with a low risk of causing myopathy. Rosuvastatin may be the best choice. Fluvastatin and pravas- tatin can also be considered, but they are less potent and may require high doses.  Consider not treating hyperlipidemia in frail older adults, as low cholesterol levels are associated with increased Continued from front page
Lipid Lowering Therapy for Special Groups
Adults with Frailty Frailty is often defined by the Fried
criteria of unintentional weight loss, fatigue, weakness, slow None of the aforementioned studies included people in their walking speed, and low levels of physical activity. It has late 80s or older. Nor did they include frail older adults, long been known that among frail older adults, low choles- who are typically excluded from drug trials. So, we don’t terol levels are associated with a higher risk of death from know for sure if such individuals will benefit from lipid- cardiovascular disease. The NCEP recommendations are silent on lipid-lowering therapy for frail elders, but many Adults in Late 80s or Older Although no research has spe-
experts suggest that they are not candidates for treatment. cifically evaluated lipid-lowering therapy in people past their mid 80s, the NCEP guidelines do not specify an upper age limit for this therapy. Based on studies of people up to their mid 80s, statin therapy for hyperlipidemia is thought likely beneficial for non-frail older adults of any age. Table 1. Risk Reduction of Coronary Events in Statin Trials that Included Older Patients
Study
Relative Risk of Coronary Events*
Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT) Collaborative Atorvastatin Diabetes Study (CARDS) Long-Term Intervention with Pravastatin in Ischemic Disease (LIPID) Propspective Study of Pravastatin in Elderly Individuals at Risk of Vascular Disease (PROSPER) Scandinavian Simvastatin Survival Study (4S) Study Assessing Goals in the Elderly (SAGE) Data from Streja et al. * Values less than 1.0 signify a reduction in risk Figure 1. Approximate Risk of Myopathy with Statins
Lowest Risk Pravastatin Fluvastatin Rosuvastatin Atorvastatin Lovastatin Simvastatin Highest Risk
References and Resources
Alexander KP, Blazing MA, Rosenson RS, et al. Management of hyperlipidemia in older adults. J Cardiovasc Pharmacol Ther. 2009;14(1):49-58.
Deedwania P, Stone PH, Bairey Merz CN, et al. Effects of intensive versus moderate lipid-lowering therapy on myocardial ischemia in older
patients with coronary heart disease: results of the Study Assessing Goals in the Elderly (SAGE). Circulation. 2007;115(6):700-707. Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001;56(3):M146-56. Jacobson TA. Overcoming 'ageism' bias in the treatment of hypercholesterolaemia : a review of safety issues with statins in the elderly. Drug Shepherd J, Blauw GJ, Murphy MB, et al. Pravastatin in elderly individuals at risk of vascular disease (PROSPER): a randomised controlled trial. Lancet. 2002;360(9346):1623-1630. Streja D, Bhat A, Streja E. Management of hyperlipidemia in the elderly. In: Hershman J, ed. Endocrinology of Aging. Endotext.com, 2009. Wenger, NS, et al. Introduction to the assessing care of vulnerable elders-3 quality indicator measurement set. Journal of the American Geriatrics Society, 2007. 55: p. S247-S252. Interprofessional care improves the outcomes of older adults with complex health problems
Editors: Rosemary Browne, MD; Barry Weiss, MD Associate Editors: Carol Howe, MD; Jane Mohler, RN, MPH, PhD; Kathryn Coe, PhD; Lisa O’Neill, MPH; and Mindy Fain, MD University of Arizona, PO Box 245069, Tucson, AZ 85724 (520) 626-5800 http://aging.medicine.arizona.edu/ Donald W. Reynolds Foundation, the Arizona Geriatric Education Center, and the Arizona Center on Aging

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