Murthy Gokula MD,CMD MEDICATIONS & LIFE EXPECTANCY DON T ROUTINELY PRESCRIBE LIPID-LOWERING MEDICATIONS IN INDIVIDUALS WITH A LIMITED LIFE EXPECTANCY: AAHPM
About Choosing Wisely First conceived by the National Physicians Alliance Funded by an ABIM Foundation grant Created 3 lists of steps physicians could take to promote more effective use of healthcare resources As much as 30% of care delivered in the US may be duplicative or unnecessary 1 1 http://www.nap.edu/catalog.php?record_id=13444
An initiative of the ABIM Foundation Choosing Wisely aims to promote conversations between physicians and patients by helping patients choose care that is: Supported by evidence Not duplicative of other tests or procedures already received Free from harm Truly necessary
The Choosing Wisely Campaign Leading specialty societies were asked to create a list of Things Physicians and Patients Should Question To date, 56 societies have released lists, some of them releasing a second or third list Consumer Reports has worked with the ABIM Foundation to maximize reach and impact of the Choosing Wisely campaign Engaged coalition of consumer organizations to disseminate content and messages about appropriate use to the communities they serve
Multiple medications Increased risk of: Receiving incorrect medications Adverse drug reactions Nonadherence Hajjar ER, et al. Am J Geriatr Pharm. 2007;5:345-351.
Multiple medications Increased risk of: Cognitive impairment Falls Functional decline Steinman MA, Hanlon JT. JAMA. 2010;304(14):1592-1601.
Multiple medications 20% of older adults take 10 medications Practice guidelines Underuse of potential medications Boyd CM, et al. JAMA. 2005;294(6):716-724. Steinman MA. Am J Geriatr Pharmacother. 2007;5(4):314-316.
Medication review Helps identify: Unnecessary medications Potentially harmful medications Underuse of medications Opportunities to reduce medication burden Drenth-van Maanen AC. Drugs Aging. 2009;26(8):687-701.
Other considerations Goals of care Life expectancy Time to benefit Burden of therapy Values/quality of life Reuben DB. JAMA. 2009;302(24):2686-2694.
EVIDENCE Total cholesterol and risk of mortality in the oldest old: Lancet 1997; 350: 1119 23 > 85 years, high total cholesterol concentrations are associated with longevity owing to lower mortality from cancer and infection Cholesterol, statins, and longevity from age 70 to 90 years. J Am Med Dir Assoc. 2013 Dec;14(12):883-8 Among older people, cholesterol levels were unrelated to mortality between the ages of 70 and 90. The protective effect of statins observed among the very old appears to be independent of TC. PHYSICIANS HEALTH STUDY: No benefit in participants aged >77 years. Consistent with a meta analysis of eight primary prevention trials in older adults (mean age 73)found fewer CV events but not lower mortality
EVIDENCE Medications used for primary or secondary prevention may have a time until benefit of years. For example, it can take from 6 months to 2 years for outcomes from statins to be achieved. What are preventive medicines: aspirin, clopidogrel, dipyridamole, warfarin, dabigatran, statins, and bisphosphonates Antithrombotics, statins, and bisphosphonates are most commonly prescribed preventive medicines in the older population Statins, followed by warfarin and aspirin are most common preventive medicines discontinued at end of life or with limited life expectancy(<1year)
EVIDENCE A 2013 Cochrane review 18 randomized controlled trials 57,000 patients aged 28 97 years Primary prevention for at least 1 year, Reduce allcause mortality (OR 0.86, 95% CI 0.79 0.94), Combined fatal and nonfatal cardiovascular disease (OR 0.75, 95% CI 0.70 0.81) Combined fatal & nonfatal cardiovascular disease events (OR 0.73, 95% CI 0.67 0.80) Combined fatal and nonfatal stroke (OR 0.78, 95% CI 0.68 0.89).1 Taylor F, Huffman MD, Macedo AF, et al. Statins for the primary prevention of cardiovascular disease. Cochrane Database Syst Rev 2013
EVIDENCE The 2013 ACC/AHA Continue statin therapy for secondary prevention> 75 if patients tolerating For patients>75, not receiving statin therapy, consider potential benefits, risks of adverse effects and drug interactions, and patient preferences when evaluating a patient for statin treatment The European Society of Cardiology and the European Atherosclerosis Society use of statins > 80 85 years is very limited, and is left to clinical judgment
WHAT,S THE PROBLEM STATINS CAUSE RHABDOMYOLYSIS MYALGIAS INCREASE ALT/AST LONG TERM USE CAUSES DIABETES Estimated NNT/NNH for primary prevention: 1,2 NNT: ~60 (heart attack), ~268 (stroke) NNH: 10 (for muscle damage)(1. BMJ. 2009 Jun 30;338:b2376.2. Cochrane Database Syst Rev. 2013 Jan 31;(1):CD004816) Kutner JS, Blatchford PJ, Taylor DH, et al. Safety and benefit of discontinuing statin therapy in the setting of advanced, life limiting illness: a randomized clinical trial. JAMA Intern Med 2015;175:691 700.
EVIDENCE Kutner & colleagues Multicenter, parallel-group, unblinded, pragmatic clinical trial Eligibility: life expectancy of between 1 month and 1 year statin therapy for 3 months or more for primary or secondary prevention of cardiovascular disease recent deterioration in functional status, and no recent active cardiovascular disease Participants were randomized to either discontinue or continue statin therapy and were monitored monthly for up to 1 year Kutner JS, Blatchford PJ, Taylor DH, et al. Safety and benefit of discontinuing statin therapy in the setting of advanced, life limiting illness: a randomized clinical trial. JAMA Intern Med 2015;175:691 700.
EVIDENCE: Kutner & Colleagues OUTCOMES MEASURED: Death within 60 days (primary outcome) Survival Cardiovascular events Performance status Quality of life (QOL) Symptoms Number of nonstatin medications Cost savings
EVIDENCE: Kutner & Colleagues 381 patients were enrolled 189 randomized to discontinue & 192 randomized to continue Mean (SD) age was 74.1:22% DEMENTIA;48.8% CANCER Proportion of participants in the discontinuation vs continuation groups who died within 60 days was not significantly different (23.8% vs 20.3%; 90% CI, 3.5% to 10.5%; P =.36) Total QOL was better for the group discontinuing statin therapy (mean McGill QOL score, 7.11 vs 6.85; P =.04). Cardiovascular events (13 in the discontinuation group vs 11 in the continuation group) Mean cost savings were $3.37 per day and $716 per patient.
EVIDENCE: Kutner & Colleagues If extrapolated to the US population, cost savings of > $600 million Stopping statin medication therapy is safe Associated with benefits including improved QOL Use of fewer nonstatin medications Reduction in medication costs. Patient-provider discussions regarding the uncertain benefit and potential decrement in QOL associated with statin continuation in this setting are warranted
Deprescribing Process Obtain a complete medication list and determine the indication for each medication Evaluate each medication s potential for drug-induced harm Determine if a medication should be discontinued by evaluating the appropriateness of the indication, whether it is being used to treat adverse effects of other medications, efficacy, benefit-to-harm ratio, treatment burden, and if the patient s life expectancy exceeds the time to therapeutic benefit (for preventive medications) Determine a plan for discontinuing medications one at time, starting with medications with the highest burden and lowest benefit Discontinue medications and monitor for withdrawal or return of symptoms Kutner JS, Blatchford PJ, Taylor DH, et al. Safety and benefit of discontinuing statin therapy in the setting of advanced, life limiting illness: a randomized clinical trial. JAMA Intern Med 2015;175:691 700.
Scott & Colleagues DEPRESCRIBING STEPS 5 essential steps Ascertain all drugs the patient is currently taking and the reasons for each one Consider the overall risk of drug-induced harm in individual patients in determining the required intensity of deprescribing intervention Assess each drug regimen for its eligibility to be discontinued Prioritize drug treatments for discontinuation Implement and monitor the drug discontinuation regimen
STATIN DEPRESCRIBING Strandberg TE Deprescribing Statins-Is It Ethical? J Am Geriatr Soc. 2016 Sep;64(9):1926-7. Among patients without existing cardiovascular disease (primary prevention), statins have been shown to reduce the risk of cardiovascular events and mortality In a survey of 180 Australian inpatients > 65 years 95% of patients were willing to discontinue statin IF prescriber agreed 94% had concerns regarding statin adverse effects. Discontinuation of statin therapy is acceptable AND is not associated with adverse effects and may even be beneficial
STATIN DEPRESCRIBING Holly M. Holmes; Adam Todd, PhD. Evidence-Based Deprescribing of Statins in Patients With Advanced Illness. JAMA Intern Med. 2015;175(5):701-702 62% of patients with cancer and a poor prognosis continued to receive statins 31%of patients with cancer filled a statin prescription within 30 days of death. Discusses Kutner & colleagues work
Choosing wisely AMDA #5 Don't routinely prescribe lipid-lowering medications in individuals with limited life expectancies