“Age is merely a number”
–Common statement from your Medspa member friend who spends thousands of dollars every month on Botox and dermal fillers
As someone who is the regular recipient of various hedged compliments with the qualifier “for your age,” I find the topic of longevity and aging simultaneously interesting and amusing. Age is definitely more than a number, but ultimately you will be fighting an uphill battle. If you’re over age 35 and in your physical prime, you were basically doing a terrible job of physical stewardship in your 20s when you were nearly invincible. But if you can find the “fun” in declining more slowly than others, then you can maybe end up being “Fast for an Old Guy” or “Look Pretty Good for Your Age” someday!
And an interesting topic of discussion is the use of medications, particularly lipid-lowering therapies (“cholesterol medications”) in older adults. We’ve all seen people on 19 different medications with competing mechanisms of action, flat-out contraindications, and duplicate prescriptions of agents that were recalled in 2016. That’s a problem. Meanwhile, some Internal Medicine doctors seem to be on a mission to de-prescribe ALL medications once people go on Medicare even if the meds are actually useful or have helped them improve their quality of life. “You’ve had a good run, Ethel. At 65 you’re barely alive anyway. You can even spend more time with your grandkids now that you don’t have to take as many trips to the Pharmacy!” This is the “You don’t have to worry about side effects if you’re dead” philosophy (popular among some insurance companies as well).
But THIS META-ANALYSIS of 11 different trials showed that use of “intensive” lipid-lowering medications was associated with 15% fewer major adverse cardiovascular events in people over age 65. This included a 16% reduction in heart attacks and 29% reduction in strokes.
However, the term “intensive” is sort of fuzzy; essentially it means something beyond the “Just Take a Statin and Pray” approach. Indeed, this conglomeration of studies was quite heterogeneous and was based on sub-analyses from various trials. These trials included use of statins, ezetimibe, PCSK9 inhibitors, bempedoic acid, and combinations of the aforementioned agents. Some trials looked at people over 65, while others started analyzing these subgroups at age 70 or even 75. A few years can make a big difference! Additionally, the RACING trial wasn’t even a cardiovascular outcome trial even though it helps support the “combo-philic” philosophy of using lower dose statins plus Ezetimibe rather than worshiping at the altar of high-intensity statins for LDL-C reduction.
So you can take a look at the individual studies and see what you think, and yes, I’m being intentionally coy in this analysis. I don’t want the Biotech Thought Police to come and haul me away for discussing specific medications that aren’t yet generic, and I don’t want people who don’t know me to accuse me of being a Pharma Shill, either. However, I’ll give you a few things to consider when having conversations about lipid-lowering therapy in elderly populations:
-Obviously there is a big difference between a 70 year-old who is playing Pickleball every day and a 70 year-old with Stage IV heart failure. And in this sense, age is MUCH more than a number and it shouldn’t discourage us from using the same individualized and thoughtful approach to risk stratification and prescribing medications that we would employ in younger folks.
-For what it’s worth, there is another open label trial (not included in this meta-analysis) called EWTOPIA-75 of ezetimibe monotherapy in elderly Japanese patients that showed a 34% reduction in cardiovascular events.
-Understanding potential drug-drug interactions and noting if there are hepatic or renal dose adjustments becomes even more important in Geriatrics. Don’t rely on your EHR alerts; you probably ignore all of those anyway. But know that certain lipid-lowering medications “play very well with others” while others might lead to greater potential for toxicities. Ultimately, combination therapy is pretty smart, as usual.
The patient in front of you is so much more than a blood test, CAC score, or date of birth. Thoughtfully individualize your approach to help patients “add life to their years.” And maybe they’ll even be accused of being pretty healthy “for their age.”😊
