When no statin is best: Reassessing meds at end of life

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Sometimes eliminating a drug may be the best way to care for a dying patient. Findings comparing continued and terminated statin therapy in palliative care patients found those who discontinued statins experienced improved quality of life with no significant increase in risk of death.

Research published online March 23 in JAMA: Internal Medicine explored the safety, clinical outcomes and cost impacts on discontinuing statins among patients with life expectancy of between one month and one year. The multicenter pragmatic trial ran from 2011 through 2013 and enrolled 381 patients. Patients were either told to continue statins (192 patients) or discontinue statin use (189 patients). Cancer was the primary diagnosis in almost half of patients (48.8 percent); more than half had concurrent cardiovascular disease (58 percent).

From enrollment, Jean S. Kutner, MD, MSPH, of the University of Colorado School of Medicine in Aurora, and a cadre of global colleagues collected data weekly for the first month and then monthly until death or one year. Phone follow-ups also occurred at weeks two, four, eight, 12, 20 and 24.

Between the continuation and discontinuation groups, mortality by 60 days was not statistically significant (20.3 percent vs. 23.8 percent, respectively), they found. Mean survival for all patients was approximately 30 weeks. Mean survival between continuation and discontinuation of statins was 190 days and 229 days, respectively. Due to the similarity in 60-day mortality, noninferiority could not be reached.

They reported no significant differences between the two groups for cardiovascular-related events nor the time to event. Only a small number of cardiovascular-related events were reported: 11 among the continuation group and 13 in those who discontinued statin treatment.

Patients reported significantly higher quality of life without statins. Patients also saved $3.37 per day, a total of $716.46 per patient. If patients were prescribed a generic, daily savings would total $2.96 per day, $629.30 per patient. This related to a totaled potential savings of $603 million across the U.S.

“There is an increasing evidence base that discontinuation of some therapies may be beneficial for selected patient populations,” wrote Kutner et al.

“If the results we report—improved [quality of life], no significant differences in mortality, and modest cost savings—had been produced by a randomized clinical trial of a new drug in patients with advanced life-limiting illness, the trial would be heralded as a breakthrough and there would be discussion of how to speed access to this new drug. The same energy needs to be applied to determining when it is appropriate for physicians to discuss discontinuing statin therapy with their patients,” they wrote.