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Consider time-to-benefit when prescribing statins

JAMA Internal Medicine
Reuters Health - 20/11/2020 - Primary prevention with statins can reduce cardiovascular (CV) events in some adults aged 50 to 75, if they have a life expectancy of at least 2.5 years, according to a new meta-analysis.

Treating 100 adults with no known CV disease with statins for 2.5 years would prevent one major adverse cardiovascular event (MACE) in one patient, Dr. Lindsey C. Yourman of the University of California, San Diego, and colleagues report in JAMA Internal Medicine.

"It takes at least 2.5 years treating 100 patients before you prevent ANY cardiovascular event in ONE of your patients," Dr. Yourman told Reuters Health by email. "So, for patients that have advanced illness with a life-expectancy of less than 2.5 years, or who have a lot of other pressing medical problems, checking cholesterol and starting a statin should be lower on the priority list if at all."

Statins are recommended for adults aged 40 to 75 years at elevated risk of CV disease, typically defined as having at least a 7.5% chance of MACE within the next 10 years, Dr. Yourman and her team note. The drugs are associated with myalgia in up to 30% of patients, and have the potential to interact with several commonly used mediations.

To estimate how long statin treatment would need to last in order for its benefits to outweigh its risks, the authors looked at eight randomized controlled trials of statins for primary prevention in adults 55 and older, including more than 65,000 participants who were followed for an average of two to six years. The study's primary outcome was time to absolute-risk reduction (ARR) threshold for treated versus untreated patients.

Based on a meta-analysis, the researchers estimate that the time to benefit (TTB) of statin treatment was 2.5 years with 100 patients. To avoid one MACE for every 200 patients treated, the TTB was 1.3 years, and it was 0.8 years with 500 patients.

Just one of the studies suggested a mortality benefit.

"In general, it is important to think about time-to-benefit of interventions that we recommend to older adults so that we can better prioritize their care in line with what they are most likely to benefit from during their lifetime," Dr. Yourman said. "Recommending interventions whose time-to-benefit is greater than a patient's life expectancy makes it more likely that we will harm than help a patient."

"In contrast, if you have a patient whose life expectancy is more than 2.5 years or who has few medical issues and has some cardiovascular risk factors like elevated blood pressure and/or moderately elevated cholesterol, then it makes more sense to start a statin medication," she added.

"Ultimately, knowing the time to benefit of a medication like a statin better helps docs to engage in shared decision-making with their patients and prioritize care according to what matters most to each patient and what their particular patient is most likely to benefit from based on their life expectancy and other medical conditions," Dr. Yourman said.

"Some patients may be willing to take a pill that is less likely to benefit them in their lifetime, just in case it will help, and that is alright, but they deserve to know how likely it is to benefit vs. harm them so that they can make that decision," she added. "The potential harms of statins (such as myalgias) may not be a big deal to some patients but may be a big deal to other patients, so again, it comes back to individualizing care and shared decision-making."

The study did not have commercial funding. The researchers did not report ties to drugmakers.

By Anne Harding

SOURCE: https://bit.ly/2ISAA7K JAMA Internal Medicine, online November 16, 2020.

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