I just completed a week on the inpatient palliative care consult service.  Here at University of Colorado, like any medical center, we see lots of people living with serious illness. Still, at least 75% of the patients I saw last week are still on a Statin?!  When I asked their primary teams they pointed out they were following the guideline.

MJ is 81 years old and has lived an active life as an academic and outdoorsman. After Thanksgiving an abdominal mass was found on a MRI to work up sciatica. Pancreatic Cancer.  Since then there has been pain, weight loss, debility – you get the picture.   On a Saturday morning we went to meet him and his wife for our initial consult.  The nurse was with him encouraging him to take his Lipitor.   He had never had any vascular disease so this was primary prevention.  He also did not have a history of HTN or DM so no other cardiac risk factors that might mediate indications for cholesterol management.   He was grateful for our help with intractable pain but also by reviewing his medications and encouraging deprescribing, starting with the Lipitor.

The ACA/AHA Guidelines acknowledge that there is limited support for primary prophylaxis that is taking cholesterol lowering medication without evidence of cardiovascular disease.  For people over 75 there is no demonstrated benefit.

How you word the guidelines makes all the difference.  In the context of a clinician reading a guideline about the management of high cholesterol, the phrase “it is reasonable to treat…”  implies that treating older adults with LDL cholesterol level higher than 70 mg/dL may be the recommended course of action. However, it is incumbent on practicing physicians not to simply adhere to guidelines, but to critically assess and interpret them in the context of each patient’s care.

A small change in practice can improve quality of life, reduce exposure to medications without benefit and reduce cost.