I can’t deny the benefits of statins – how they have revolutionized our approach to managing patients after a heart attack. People are living longer.  Heart attack used to be considered fatal but is now viewed as a minor event if treated promptly.  After a heart attack, the patient is bombarded with a cocktail of pills   — all of them have strong scientific evidence to either improve the heart function, reduce risk factors or ultimately improve survival.  Statin (short for HMG-CoA reductase inhibitor) is one of them. It is a class of medications used to lower blood cholesterols. Some examples include atorvastatin (Lipitor), rosuvastatin (Crestor) and simvastatin (Zocor).

In addition to lowering blood cholesterol, statins can help to prevent subsequent heart attacks or strokes and help patients to live longer.  So statins are often prescribed indefinitely – yes to take for the rest of your life.

That’s great, except now we have many patients with dementia living in nursing homes, still on a statin to improve survival when the benefit has become questionable. Some physicians would get rid of the statin in no time. Other would be totally against such an idea. Families and loved ones may misinterpret stopping the statin as “giving up” on the patient.

There are some controversial discussions on how statins may contribute to cognitive impairment and memory loss too.[1]  But the latest thinking is that statins offer protective benefits against dementia.[2] Statins have other side effects: they can be harmful to the liver, may cause muscle weakness and pain and result in rhadomyolysis, a severe form of muscle toxicity that may lead to renal failure.

I don’t have a strong view whether patients should continue their statins or not once they are in a nursing home with advanced dementia.  But I do suggest cutting the dose to the lowest possible. After all, the diet is well controlled in this setting and the benefit of statin (if any) is not on lowering the cholesterol numbers anymore.  Further, when pill burden becomes an issue or the goal of care is shifted to palliative care, it is probably time to revisit whether we still need the statin.

In 2012, statins are consider the 2nd highest proportion of drug spending in Canada (excluding Quebec), costing just over $400 million[3]. Statins are great but costly to our system. So I hope all clinicians would prescribe statins more responsibly and judiciously.

[1] http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm293330.htm

[2]Wannamaker BL et al. Cholesterol, Statins, and Dementia: What the Cardiologist Should know. Clin. Cardiol. 38, 4, 243–250 (2015)

[3] https://secure.cihi.ca/free_products/Prescribed_Drug_Spending_in_Canada_EN.pdf

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