There is increasing awareness that patients nearing the end of life should take fewer medications.¹ Older patients often regularly take multiple prescriptions – a situation known as polypharmacy. While these medications can extend life – under general circumstances – they may also come with unwanted costs and side effects. When one disease such as cancer puts a person’s life expectancy to twelve months or less, the pros and cons for some medications changes. In fact, at the end of life, stopping some chronic disease medications has been shown to improve quality of life.² Statins, in particular, have been part of this debate.

What Are Statins?

Statins are a class of lipid-lowering drugs prescribed to reduce the risk of cardiovascular injuries such as heart attack and stroke. Popular statins include atorvastatin (Lipitor), fluvastatin (Lescol XL), lovastatin (Altoprev), pitavastatin (Livalo), pravastatin (Pravachol), rosuvastatin (Crestor, Ezallor) and simvastatin (Zocor, FloLipid).

What Are the Side Effects of Statins?

With some adjustments from doctors, most patients can find statins that work for them. However, the list of potential and often-tolerated side effects is long. These include muscle pain, muscle damage, increased blood sugar, memory loss, and confusion. The Mayo Clinic reports that memory loss and confusion associated with statins have been known to reverse when statins are discontinued.  People over 80 are more prone to statin’s side effects. Hospice patients, in particular, may be less capable of tolerating polypharmacy.³  

Barriers to Deprescribing

Deprescribing means stopping a prescription to reduce the risk of side effects, adverse events, or otherwise improve quality of life. End-of-life care stands out as a logical time to start deprescribing medications that are no longer relevant to a patient’s health and wellbeing. Unfortunately, deprescribing may not be occurring as soon or as often as it should. One in three hospice nurses say they wish they had more information about how and when to discuss deprescribing.⁴

Deprescribing should occur through collaborative decision making between clinicians and patients or their family. Nevertheless, clinicians frequently cite concerns over patient reactions to the topic. They report that patients take deprescribing as a sign of abandonment.⁵ On the other hand, a recent survey found that less than 10% of patients would perceive deprescribing statins as abandonment.⁶ More respondents recognized how deprescribing statins could save them money or improve quality of life. This was among people with a life expectancy of less than 12 months. The survey is of limited value, though. It was conducted among patients who had already agreed to a trial that would randomly choose people to have statins deprescribed. Therefore, these patients were already agreeable to giving up their statins.

What Patients and Families Should do About Cholesterol-Lowering Medication Near the End of Life

The message for patients and families is to be your own advocate. Know that discontinuing statins may offer benefits in terms of reduced costs and improved quality of life. However, decisions like these should only be made in collaboration with prescribers. When there is a life expectancy of less than 12 months, ask for a meeting for medication review, and discuss the pros and cons of each medication that was prescribed previously.     

References:

1. Scott IA, Hilmer SN, Reeve E, Potter K, Le Couteur D, Rigby D, Gnjidic D, Del Mar CB, Roughead EE, Page A, Jansen J. Reducing inappropriate polypharmacy: the process of deprescribing. JAMA Internal Medicine. 2015 May 1; 175 (5): 827-34.
2. Kutner JS, Blatchford PJ, Taylor DH, Ritchie CS, Bull JH, Fairclough DL, Hanson LC, LeBlanc TW, Samsa GP, Wolf S, Aziz NM. Safety and benefit of discontinuing statin therapy in the setting of advanced, life-limiting illness: a randomized clinical trial. JAMA Internal Medicine. 2015 May 1; 175 (5): 691-700.
3. Cadogan CA, Ryan C, Francis JJ, Gormley GJ, Passmore P, Kerse N, Hughes CM. Improving appropriate polypharmacy for older people in primary care: selecting components of an evidence-based intervention to target prescribing and dispensing. Implementation Science. 2015 Dec; 10 (1): 161.
4. Meyer S. Deprescribing in Terminal Illness: The Role of the Hospice Nurse. Xavier University. 2020.
5. Scott IA, Anderson K, Freeman CR, Stowasser DA. First do no harm: a real need to deprescribe in older patients. Medical Journal of Australia. 2014 Oct; 201 (7): 390-2.
6. Tjia J, Kutner JS, Ritchie CS, Blatchford PJ, Bennett Kendrick RE, Prince-Paul M, Somers TJ, McPherson ML, Sloan JA, Abernethy AP, Furuno JP. Perceptions of statin discontinuation among patients with life-limiting illness. Journal of Palliative Medicine. 2017 Oct 1; 20 (10): 1098-103.