Home' Australian Pharmacist : Australian Pharmacist January 2016 Contents Australian Pharmacist January 2016 I © Pharmaceutical Society of Australia Ltd.
result of drug-drug interactions rather
than a specific adverse response to
statin monotherapy.2 Such interactions
inevitably result in higher plasma
concentrations of a statin and thereby an
increased risk of myopathy. Multiple drug
use, drug interactions and altered drug
metabolism may put the elderly patient
at increased risk of myopathy when
statins are administered.
is therefore advocated in the use of these
drugs in elderly patients.
In this regard,
pravastatin and fluvastatin are least likely
to provoke muscle cell damage, which in
part, relates to not being metabolised by
the cytochrome P-450 3A4 pathway.
Cognitive and neurologic symptoms have
been reported, but there is no consistent
evidence supporting a cause-effect
relationship between statin use and
confounding difficulties in diabetes risk
assessment because patients with higher
CVD risk also have an increased baseline
risk of developing diabetes, convincing
evidence has been presented that
statins are associated with a small but
statistically significant risk of developing
Their use is
associated with one new diabetes event
per 1,000 person-years of treatment
(or one additional case per 255 patients
taking statins over 4 years), which is very
small. It appears that statins adversely
affect glucose homeostasis in parallel
with their 3-hydroxy-3 -methylglutaryl-
coenzyme A inhibition capacity.
been suggested that the clinical impact
of statin-associated diabetes is likely to be
unimportant.32 The excess risk of diabetes
appears to be confined to those who are
already at risk for developing diabetes.
Diabetes is diagnosed only 2–4 months
earlier, on average, in these statin-treated
patients and therefore is unlikely to have
long-term adverse consequences. It is
likely that the cardiovascular risk reduction
benefit from statins far outweighs the
potential for adverse effects in all but the
very lowest risk individuals.32
The consistent message from Australian
and American guidelines is that the
decision to treat older individuals with
statins must be individualised.
Shared decision making is paramount.
In primary prevention, each patient’s
characteristics predisposing to adverse
effects, as well as quality of life, should
be considered in the decision to start
treatment, balancing the probable
benefits with the potential risks.
The strategy for reducing CVD risk in
primary prevention begins with an
estimation of absolute CVD risk for
the individual.33 This initiates a risk
discussion, leading to a decision that
considers scientific evidence (or lack
thereof ), clinician knowledge of the
patient’s specific attributes, and informed
In the case of Mr Miller, his absolute
CVD risk is estimated to be 14% within
the next five years (total cholesterol
of 6.1 mmol/L and HDL cholesterol
of 1.8 mmol/L; systolic BP is 150
This corresponds to a moderate risk,
and statin therapy is appropriate,
if acceptable to Mr Miller. He also is not
on multiple drug therapy, so there is a
low risk of drug interactions.
It should also be remembered that
smoking cessation, regular physical
activity and healthy diet are, as in
younger individuals, appropriate and
effective measures for preventing
cardiovascular events in the elderly.
The definitive advice on statin use as
a primary prevention strategy in older
individuals may come from Australian
researchers. A large 5-year primary
prevention randomised clinical trial
(n = 12,000) comparing atorvastatin
(40 mg/day) with placebo in healthy
people older than 70 years (Statins
for Reducing Events in the Elderly
[STAREE]) is now underway, with
primary end points of total mortality or
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