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Discontinuation of statin use near end of life improved QOL
CHICAGO — Discontinuation of statin therapy in patients with limited life expectancy improved overall quality of life without compromising survival, according to results of a multicenter, unblinded trial presented at the ASCO Annual Meeting.
Patients with terminal illness often take 10 or more different pills per day. The regimens can become burdensome for those who have poor appetite or difficulty swallowing. Also, the side effects of each pill accumulate and interactions between various drugs can limit the efficacy of individual treatments, researchers wrote.
Amy P. Abernethy
“While we are innovating and improving the treatment for cancer and survival from cancer, we also need to think about how we can innovate with palliative care and how we can improve care at the end of life,” Amy P. Abernethy, MD, PhD, a medical oncologist and palliative care specialist at Duke University Medical Center, said during a press conference. “The number of pills in the ‘pill cup’ doubles at the end of life. For people with life-threatening illness, the optimal management of these medications — including which ones we can discontinue — is a critical question for which [the answer is] uncertain.”
Abernethy and colleagues sought to assess whether discontinuation of statin therapy was safe for patients with less than 1 year to live.
The study included 381 patients with life-limiting illness, about half of whom (49%) had cancer. All patients had a life expectancy between 1 month and 1 year. All patients had taken statins for at least 3 months, and 69% had used statins for more than 5 years.
Abernethy and colleagues randomly assigned patients to continue statin use (n=192) or discontinue use (n=189).
The rate of death within 60 days of randomization — the study’s primary endpoint — was 23.8% among the discontinuation group and 20.3% among those who continued statin use (90% CI, -3.5% to 10.5%). Median time to death was longer among those who discontinued statin use (229 days; 90% CI, 186-332) than those who continued statin use (190 days; 90% CI, 170-257).
Patients who discontinued statins also experienced significantly better total quality of life (McGill Quality of Life Questionnaire score, 7.11 vs. 6.85; P=.037) and fewer symptoms (Edmonton Symptom Assessment Scale score, 25.2 vs. 27.4; P=.128).
Those who discontinued statins took significantly fewer medications (10.1 vs. 10.8; P=.034). Thirteen patients in the discontinuation group and 11 in the continuation group experienced cardiovascular events.
When Abernethy and colleagues assessed the average cost savings per patient, they found those who discontinued statins saved $3.37 per day and an average of $716.46 over the course of the trial.
When applied to 2014 population estimates, the potential cost savings associated with statin discontinuation in the last year of life could reach $603 million, Abernethy said. When applied to population estimates for 2040, the savings could reach $1 billion.
“Discontinuing statins during the last year of life does not adversely affect 60-day mortality or overall survival,” she said. “In fact, benefits were observed, including improved total quality of life, fewer medications, a trend toward fewer symptoms and improved satisfaction, and lower overall costs. Although we still think this is a patient-centered decision, and patients and clinicians should talk together about what to do, as clinicians we can now feel confident that we are not harming our patients by making [the decision to discontinue statins].”
For more information:
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Abernethy AP. Abstract #LBA9514. Presented at: ASCO Annual Meeting; May 30-June 3, 2014; Chicago.
Disclosure: The research was supported by the National Institute of Nursing Research and the NIH. The researchers report no relevant financial disclosures.
Perspective
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These are very difficult decisions that we have to make as clinicians. No one wants to ‘rock the boat’ at this stage of life, and continuing medications that have no benefit for prevention of future disease generally makes sense in this situation. Now with this trial, we as clinicians can feel comfortable having discussions with our patients and their families about the fact that stopping these medications will not have any adverse outcomes and may be beneficial to the patient in their last week or month of life.