The Editorial Executive Committee welcomes letters, which should be less than 250 words. Before a decision to publish is made, letters which refer to a published article may be sent to the author for a response. Any letter may be sent to an expert for comment. When letters are published, they are usually accompanied in the same issue by their responses or comments. The Committee screens out discourteous, inaccurate or libellous statements. The letters are sub-edited before publication. Authors are required to declare any conflicts of interest. The Committee's decision on publication is final.

Letter to the Editor

Editor, – The recent article (Aust Prescr 2013;36:79-82) suggests statins could be less effective in older patients, may have more adverse effects and should be used in lower doses.

While this may be true in seriously ill patients or those with dementia, we feel that there is insufficient evidence to follow this advice in otherwise fit elderly people. The fact that the relationship of cholesterol to cardiac events in the elderly is less consistent does not negate trials showing a decrease in events no matter what the starting cholesterol is, or the greater decrease in events in higher compared to lower dose statins. With an increased incidence of events in the elderly, the absolute drop with statins may well be greater.

The evidence on loss of memory with statins is minimal in otherwise fit elderly patients. There are anecdotal reports of this only. Myopathy requires drug cessation but this is in the minority of patients. Risks with liver enzyme elevation appear slight at the most.

We feel that following the advice in the article could increase cardiac and other atherosclerotic events in otherwise well elderly people.

Mark Sheppard

Alistair Begg

SA Heart

Authors' comments

Sarah Hilmer and Danijela Gnjidic, the authors of the article, comment:

We thank Mark Sheppard and Alistair Begg for pointing out the limitations of making clinical judgements based only on chronological age. In older people, in the presence of increasing inter-individual variability, biological age, which is analogous to the degree of frailty, is a much better predictor of outcomes than chronological age. Amongst older people, frailty affects the use, pharmacokinetics, pharmacodynamics, safety and efficacy of medicines.1,2

Clinical trials in older people do not show benefits of statins for primary prevention of cardiovascular disease.3 The participants in these trials are generally fit. The frail are predominantly excluded based on comorbidity, co-medication or impaired physical or cognitive function. In frail older people, we know more about adverse events (from observational studies) than we do about efficacy, which requires randomised controlled trials.4

We wish to clarify what is known about adverse effects of statins in fit older people. The majority of the evidence that statins cause cognitive impairment is from case reports and case series, in which the impairment was generally reversible within days to weeks of stopping the statin. Therefore, if statin-associated cognitive decline is suspected, it is reasonable for clinicians to consider a trial of statin withdrawal. Amongst clinical trial participants who were generally fit, myalgias were reported in 5–10%, myositis in 0.1–0.2%, and rhabdomyolysis was rare. A clinician treating one hundred fit older patients, 40% of whom are taking statins, is expected to see 2–4 patients with myalgias. The elevated hepatic transaminases observed with statins are of uncertain clinical significance.

The prescription of statins for primary prevention should be individualised on the basis of clinical judgement.5 Our article aims to raise awareness of the benefits and risks of statins to help clinicians apply the existing evidence to their patients.


  1. Hilmer SN, Gnjidic D, Le Couteur DG. Thinking through the medication list - appropriate prescribing and deprescribing in robust and frail older patients. Aust Fam Physician 2012;41:924-8.
  2. Cerreta F, Eichler HG, Rasi G. Drug policy for an aging population - the European Medicines Agency's geriatric medicines strategy. N Engl J Med 2012;367:1972-4.
  3. Baigent C, Keech A, Kearney PM, Blackwell L, Buck G, Pollicino C, et al. Efficacy and safety of cholesterol- lowering treatment: prospective meta-analysis of data from 90,056 participants in 14 randomised trials of statins. Lancet 2005;366:1267-78.
  4. Hilmer SN, Gnjidic D, Abernethy DR. Pharmacoepidemiology in the postmarketing assessment of the safety and efficacy of drugs in older adults. J Gerontol A Biol Sci Med Sci 2012;67:181-8.
  5. Reiner Z. Statins in the primary prevention of cardiovascular disease. Nat Rev Cardiol 2013;10:453-64.