Lipid-lowering drug prescription decreases with age but increases with frailty
Prescription patterns of lipid lowering agents among older patients in general practice: an analysis from a national database in the NetherlandsLiterature - Kleipool EEF, Nielen MMJ, Korevaar JC et al. - Age and Ageing 2019; doi: 10.1093/ageing/afz034
Introduction and methods
According to Dutch guidelines, lipid-lowering drugs (LLDs) are recommended for patients with prior CVD because of their (very) high CV risk . In subjects without CVD, every male and almost every female ≥70 years of age without CVD is eligible for LLDs to prevent CVD-related morbidity and mortality, solely based on their age, according to a risk stratification tool that estimates 10-years risk of a CV event or mortality .
There are only little data on prescription patterns of LLDs in older people in relation with age, frailty and comorbidities. Particularly older and frail adults with a shorter life expectancy may receive preventive drugs less often, because they may be less likely to benefit from LLDs and more likely to be harmed . A previous study has shown reduced statin treatment in older patients with and without pre-existing CVD and high comorbidity-scores, compared to those with fewer comorbidities . Also, risk of institutionalization and mortality was not reduced with statin therapy in frail older men ≥70 years of age .
This study (n=224.328) assessed how many people ≥70 years, with (n=55.309) and without (n=189.019) prior CVD, were prescribed an LLD, according to age, level of frailty, and number of comorbidities, using data from the large Nivel Primary Care Database (NIVEL-PCD) in The Netherlands (2011-2015). LLDs were defined as drugs belonging to the C10 ‘Lipid-modifying agents’ category (e.g. statins and fibrates), in the Anatomical Therapeutic Chemical (ATC) classification system. Vascular and non-vascular comorbidities were recorded using the International Classification of Primary Care-1 (IPCS-1) of the WHO. Atherosclerotic-related CVD at baseline was defined as: angina pectoris, acute MI, MI >4 weeks ago, TIA, stroke, or peripheral artery disease. Prevalence of LLD use was examined according to age (70-74, 75-80, 81-84, 85-90 and ≥91 years of age), frailty (tertiles based on the Drubbel-frailty index), number of chronic disease at baseline (0-3, 4-8, ≥9) and number of primary care visits during the first year after baseline (0-3, 4-8, ≥9).
- LLDs were prescribed in 68.8% of participants with CVD at or after baseline and in 35.7% of those without CVD.
LLD use according to age
- In the CVD group, LLD use at baseline was seen most often in the youngest group studied and declined with increasing age (ranging from 77.8% in those aged 70-74 years to 28.9% in those aged ≥91 years).
- In subjects without CVD, a similar trend was seen; LLD use declined with increasing age (ranging from 37.4% to 12.2%), with the exception of those aged 75-80 years, of whom 39.6% were prescribed LLDs.
LLD use according to age and frailty
- In those with CVD, the prevalence of LLD use was almost 20% points higher in the most frail patients vs. the least frail (70-74 years: 81.5% vs. 63.3% and ≥91 years: 31.3% vs. 15.3%).
- In participants without CVD, similar trends for LLD use were found; LLD use declined with increasing age and increased with higher levels of frailty within each age group.
LLD use according to age, comorbidities and primary care visits
- Regardless of age, LLD use increased with increasing number of chronic disease, total number of drugs used and primary care visits.
An analysis of a large Dutch primary care database showed that general practitioners are less likely to prescribe LLD treatment with increasing age in subjects ≥70 years. Contrary to expectations, LLD use was seen more often in frail older adults compared to non-frail older adults. In this group, the benefits may, however, not outweigh the harms of LLD. Thus, competing risks, time-to-benefit vs. estimated life expectancy and level of frailty should be taken into account in decision-making on LLDs in older individuals.