Dyslipidemia Treatment in the Elderly: A Pharmacologic Overview

The current prevalence of dyslipidemia is 30% to 70%, and it is well known that cardiovascular disease (CVD) is a major cause of worldwide morbidity and mortality. Although statins have been shown to have an “unequivocal” benefit in reducing atherosclerotic cardiovascular disease (ASCVD), the use of these medications in the elderly population (adults >75 years old) is controversial.¹

Led by Wilbert S. Aronow, MD, professor of medicine and senior associate program director of the Cardiology Fellowship Program at Westchester Medical Center in Valhalla, New York, researchers conducted a review of drug therapy for dyslipidemia in elderly patients, published in Drugs and Aging.¹

Previous research has shown that prevalence of CVD, including ischemic heart disease and stroke, increases substantially from 40% at ages 40-59 years to 70%-75% at ages 60-79 years and again to 79%-86% at age ≥80 years.² In addition, after an initial acute myocardial infarction (MI) in adults, there is a ≤20% risk for recurrent acute MI within 5 years.³ Taken together, these data “highlight the tremendous ASCVD burden in the elderly,” according to Dr Aronow and colleagues.¹

Currently, there are several drug categories that affect cholesterol metabolism that can be used to manage dyslipidemia, particularly low-density lipoprotein cholesterol (LDL-C), the primary lipid measurement used for risk evaluation.^1,4 Available drug categories include ezetimibe, niacin, proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors, fibrates, omega-3 fatty acids, and statins.

Ezetimibe

Several studies have evaluated the safety and efficacy of ezetimibe-plus-statin combination therapies in patients age ≥65 years.¹ A pooled analysis of 4 randomized controlled trials (RCTs) found this therapy “demonstrated greater efficacy in reducing plasma levels of LDL-C regardless of age grouping.”¹ Similarly, the landmark IMPROVE-IT (ClinicalTrials.gov identifier NCT00202878) study found that simvastatin-plus-ezetimibe combination therapy resulted in significant reductions in the incidence of primary composite endpoints, including cardiovascular (CV) death, major coronary event, or nonfatal stroke. This particular combination therapy resulted in a 20% reduction in the incidence of the primary endpoint in participants age ≥75 years compared with a 3% reduction in the <75-year age group.¹

“These findings support the safe and efficacious addition of ezetimibe to statin therapy in an older patient population,” Dr Aronow and colleagues noted. “The current indication for ezetimibe in the management of dyslipidemia is only for secondary prevention.”¹

Niacin

Because of its unique, broad effect on lipid metabolism, niacin (nicotinic acid) has been used as a dyslipidemia treatment since the 1950s¹; however, despite early clinical trials demonstrating CV benefits,¹ 2 large-scale RCTs (AIM-HIGH [ClinicalTrials.gov identifier NCT00120289] and HPS2-THRIVE [ClinicalTrials.gov identifier NCT0046130]) did not confirm that these benefits exist.¹

In AIM-HIGH, researchers found that, despite “favorable changes in cholesterol parameters,” no significant difference in the primary composite endpoint — CV death, nonfatal MI, ischemic stroke, or high-risk acute coronary syndrome — was noted in the 3414 patients included in the study.¹ Similarly, in HPS2-THRIVE, results showed “no significant reduction in the incidence of major vascular events… in the niacin-laropiprant group when compared with placebo.”¹

“The results of AIM-HIGH and HPS2-THRIVE suggest the lack of additional benefit of raising [high-density lipoprotein cholesterol] levels with niacin once LDL-C is at an optimal level,” Dr Aronow and colleagues wrote.¹ “Considering the lack of benefit and the increase in adverse events associated with niacin, this medication should not be used in an elderly population.”¹

This article originally appeared on The Cardiology Advisor