The ATP III guidelines [57] noted that when statins are not sufficient to lower high cholesterol, bile acid sequestrants also known as resins could be added. More recently, the 2016 ACC expert consensus on non-statin therapies for LDL-C lowering [16] stated resins may be considered in select circumstances as a second-line agent for adults with ezetimibe intolerance and with triglycerides
Fibrates
While fibrates (gemfibrozil, fenofibrate, clofibrate) have not been studied to demonstrate a reduction in CVD or CVD mortality in the elderly population, this medication class is beneficial in patients with hypertriglyceridemia to lower triglyceride levels and prevent pancreatitis. Fibrates are recommended for patients with triglyceride levels approaching 500 mg/dL. Fibrates can also increase high-density lipoproteins, which tend to be lower in the elderly population and considered a risk factor for CVD. Gemfibrozil is not recommended in combination with statin therapy due to an increased risk of myalgia. Fenofibrate is the drug of choice, particularly for diabetic patients with very uncontrolled triglyceride levels because it will not affect glucose levels [57]. At this time, we do not recommend the use of fibrates in the elderly population unless they are at risk for developing pancreatitis and have elevated triglyceride levels.
Patient-Centered Care
Evidence-based medicine can aid in making sound clinical decisions for proper patient care; however, treatment plans should consider the individual patient’s perspectives and needs, beliefs, expectations, and goals. In the elderly population, we must also consider factors such as finances, pill-burden, drug-drug interactions, physiological needs, comorbid disease states, and overall life expectancy. In addition, the elderly population is physiologically heterogeneous group and recommendations for therapy need to be individualized. Chronological age does not necessarily correspond to vascular age and risk factors for cardiovascular disease do not predict outcomes as well in the elderly as they do in younger patients. While older patients may view having to take 1 less medication as more important than preventing a heart attack or stroke at the age of 80, it is advisable to discuss all potential outcomes related to morbidity associated with the occurrence of an MI or stroke due to the lack of statin therapy. Additionally, pharmacists can play a vital role in evaluating elderly patients and their medication regimens. Elderly patients should undergo a medication reconciliation at each visit to evaluate drug-drug interactions, side effects, and potentially harmful medication combinations that may lead to increased adverse drug outcomes.
Conclusion
CHD increases with age, and most patients who have a CV event are more likely to die with advancing age. Based on the the limited available evidence, statin therapy is beneficial in the elderly population in reducing overall CV morbidity. We recommend beginning with with a moderate-intensity statin and adjusting accordingly. High-intensity statin therapy appears to be effective for elderly patients for secondary prevention, but clinicians should use clinical judgment and monitor for adverse events, particularly myalgia pain. At this time, we are unable to determine if non-statin therapies for the elderly would be beneficial and do not recommend their use unless the patient is at risk for pancreatitis, in which case a fenofibrate is recommended.
Corresponding author: Nicole A. Slater, PharmD, BCACP, Auburn University, Harrison School of Pharmacy, 650 Clinic Dr., Mobile, AL 36688.
