Polypharmacy: Statins and other drugs you may consider deprescribing

Polypharmacy is a growing problem in the United States and many other countries throughout the world. In fact, a full 35.8% of older adult Americans take five or more medications at a time, and approximately 15.1% of them are at risk for a potential major drug-drug interaction, according to results of a longitudinal, nationally representative study.

To circumvent potential problems in patients taking multiple medications, clinicians must carefully evaluate which are appropriate and which may not be. This is especially true for elderly patients, who are not only more likely to be taking several different medications, but are also more likely to suffer detrimental effects as a result.

Experts at the American Geriatrics Society are currently in the process of reviewing a 2018 update of the Beers Criteria, the latest version of which was published in 2015. The 2018 Beers Criteria will be updated to include information on the harms and benefits of particular medications in the elderly, possible interactions with other drugs, and drugs to avoid.

In the meantime, here’s a look at some common medications that have been shown to have deleterious effects in the elderly that you may want to consider deprescribing:

Statins for primary prevention:  Currently, no evidence exists to prove the benefits of statins for the primary prevention of cardiovascular events in patients over 75 years old. Thus, researchers recently conducted a large, retrospective cohort study in 46,864 patients aged 75 years or older (mean age: 77 years; median follow-up 5.6 years) without clinically diagnosed atherosclerotic cardiovascular disease to assess the effects of statin treatment on cardiovascular mortality. They found that in those older than 74 years who did not have type 2 diabetes, statin treatment did not reduce the incidence of atherosclerotic cardiovascular disease or all-cause mortality.

Proton-pump inhibitors (PPIs): In a recent study, researchers from the US Department of Veterans Affairs found that mortality risks may be high in PPI users (HR: 1.15; CI: 1.14-1.15) compared with non-users, in those without gastrointestinal conditions, and in those using PPIs for prolonged durations. Use of PPIs should be avoided long-term in the elderly. Not only do they increase the risk of Clostridium difficile infection, but up the risk of bone loss and fractures as well.

Benzodiazepines and Z drugs: In the elderly, chronic use of benzodiazepines and the Z drugs (zolpidem, zaleplon, and eszopiclone) should be avoided. The list of reasons includes increased sensitivity and increased metabolism of these agents that occur in older patients, as well as the increased risk of cognitive impairment, delirium, falls, fractures, and motor vehicle crashes. Finally, Finnish researchers of a recent nested, case-control study published in Acta Psychiatrica Scandinavica found that benzodiazepine use, in general, was associated with a modestly increased risk of Alzheimer’s disease (adjusted OR: 1.06; 95% CI: 1.04-1.08). They also found a dose-response association with both cumulative consumption of these agents and duration of use.

Aspirin: For the primary prevention of cardiovascular disease and colorectal cancer, aspirin should be used with caution in those aged 70 years and older. In a large study published in the New England Journal of Medicine, researchers followed 19,114 patients for a median of 4.7 years, and concluded that low-dose aspirin used in older persons as primary prevention carried a significantly higher risk of major hemorrhage (HR: 1.38; 95% CI: 1.18-1.62; P < 0.001 compared with placebo) and did not significantly lower the risk of cardiovascular disease.

NSAIDS: Although NSAIDs are commonly prescribed, they are one of the most common causes of adverse drug reactions in the elderly. Further, researchers of a recent review published in Aging and Disease concluded that elderly patients are very susceptible to the side effects of NSAIDS. When prescribing NSAIDs, clinicians should be cognizant of the increased risk for falls, psychiatric events, and stroke, and carefully weigh the risk/benefit ratio to optimize outcomes.