Discontinuing statins for primary prevention in older adults

The major randomized controlled trials (RCTs) that established the benefits of statins in preventing atherosclerotic cardiovascular disease (ASCVD) generally did not enroll persons older than 75 years. Once a patient who has been taking a statin for primary prevention reaches that age, are there additional benefits to continuing it, or conversely, are there harms associated with discontinuing? In 2020, a systematic review of international guidelines on cardiovascular disease prevention found “little specific guidance for physicians who are considering statin discontinuation in older adults in the context of declining health status and short life expectancy.”

A 2024 systematic review identified 35 observational studies and a single RCT comparing statin discontinuation to continuation. The observational studies showed that statin discontinuation in all age groups was associated with statistically significant increases in all-cause mortality (hazard ratio (HR) = 1.92), cardiovascular mortality (HR = 1.63), and cardiovascular events (HR = 1.31), with similar results in adults 75 years and older. The single RCT was performed in 381 older adults with deteriorating functional status and an estimated life expectancy of 1 month to 1 year. 60-day mortality was similar between the groups (23.8% with discontinuation vs 20.3% with continuation, p=0.36), and quality of life was better in the group no longer taking statins.

An expert panel recently utilized this limited evidence base to create a clinical practice guideline on deprescribing statins in older persons. A synopsis of the guideline is available in an algorithm. The guideline suggests deprescribing statins in older adults at end-of-life and continuing them for primary and secondary prevention in other adults older than 65. Several factors may prompt a conversation about statins: frailty, pill burden, functional limitations, cognitive impairment, complex care needs, and advanced illness (eg, cancer). Select patients with life expectancies greater than 1 year may reasonably decide to discontinue statins based on their personal goals and the value they assign to preventing future cardiovascular events.

The results of a pragmatic, open-label RCT published this month in The Lancet Healthy Longevity support individualized decision-making regarding statin continuation in older adults. 1,180 French adults 75 years and older who had been taking a stain for primary prevention for at least 1 year and had no evidence of dementia or another progressive life-limiting disease were randomly assigned to stop or continue taking statins. After 3 years, there were no statistical differences in all-cause mortality or cardiovascular events between the groups. However, the group that discontinued statins had no advantages in quality or life, cognitive function, functional status, symptom burden, or adverse events.

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This post first appeared on the AFP Community Blog.

Making measles great again, part 2

Six months ago, I wrote about why measles outbreaks matter to everyone. At that time, Lancaster County had recently diagnosed 5 people with measles, the first cases in Pennsylvania this year. As of today, the state Department of Health has recorded 296 cases of measles in 2026. Of those, 61 cases were confirmed in the past 7 days, most of these in Lancaster County. 52 patients became sick enough to be hospitalized; fortunately, no one has died. I am now practicing at the center of an outbreak that is threatening to become a full-blown epidemic, the likes of which we haven't seen since Covid.

It's not all Robert F. Kennedy, Jr.'s fault - but he certainly fanned the flames of anti-vaccine sentiment that brought us to this point.

The costs of a measles outbreak are not limited to patients' direct medical expenses, or even the indirect costs of missed school or work. Public health workers (Lancaster County, inexplicably, has no public health department, so we are relying on assistance from the state) are mobilized to track down contacts of ill persons and contain the spread. Vaccination clinics are organized and deployed throughout affected communities, requiring additional staff and medical resources. From February to August 2025, the New Mexico Department of Health responded to a 9-county measles outbreak that totaled 99 cases - fewer than the number we've already seen in Lancaster County this year. The estimated cost of the public health response was a staggering $5.4 million, or about $53,500 per case. Those dollars weren't just sitting in a government account waiting to be used - they had to be diverted from education, policing, highway maintenance, and other essential services.

In an incisive commentary on the "hidden costs" of a measles outbreak, Dr. Katherine Wells, the public health director of Lubbock, Texas, wrote: "When people hear that Lubbock had 50 measles cases in 2025, they often picture something manageable: a handful of sick children, some telephone calls, a few weeks of extra work. That is not what 50 measles cases look like." Instead, she explained, it looked like this:

1. An outbreak is not an event but a cascade - "a case is the start of a cascade of exposures, responses, and system disruptions that unfold over time. ... What emerges is not a series of isolated incidents but a pattern: each exposure generates conditions for the rest. Each setting does not simply experience the outbreak. It amplifies its complexity."

2. When systems bend, people improvise - "Clinics expanded capacity, added hours, and brought in additional staff where possible. But these resources did not materialize from nowhere. They were pulled from other services, such as routine immunizations, chronic disease management, [and] sexual health care - that now had to function with less."

3. The hidden erosion of emergency capacity - "An ambulance transports a patient with suspected measles. After the transfer, it must be taken offline, decontaminated, and cleared. Then it happens again. And again. Each time, the delay is measured in hours, but the impact is cumulative."

4. Survival is not the end of the story - For the sickest children, "survival ... entails extended hospital stays, ongoing clinical needs, and the quiet displacement of other patients who depend on the same finite resources."

5. The costs we do not count - "The most consequential impact [of an outbreak] lies elsewhere: in the work that did not happen."

As vaccination coverage declines in young children across the U.S., outbreaks of measles and other preventable diseases will inevitably become more common and widespread. I'll give the last word to Dr. Noel Brewer, a public health professor at the University of North Carolina, who chairs a committee that is evaluating whether the U.S. should lose its hard-won measles elimination status dating back to the year 2000:

Measles is a brutal disease that has no medical cure. Parents of children made sickest must wait it out in the hospital, despairingly wondering whether their child will die. That level of risk is indefensible in 2026 — more than 25 years after the United States achieved measles elimination. Kids are suffering and dying from a disease we already know how to prevent, and that failure is entirely ours.

The long arc of recommendations to prevent peanut and egg allergies

Our approach to preventing egg and peanut allergies has changed over the past 2 decades. At the turn of the century, the American Academy of Pediatrics (AAP) made an expert consensus recommendation that high-risk infants avoid eggs until age 2 years and peanuts until age 3 years. Unfortunately, the ensuing decade saw a substantial increase in self-reported peanut allergy prevalence, rising from 0.4% of US children in 1997 to 1.4% in 2008. Subsequent randomized trials found that introducing peanuts by age 6 months reduces the risk of developing a peanut allergy by age 5 years, leading to a reversal of the earlier recommendation.

In Australia, infant feeding guidelines were revised on a similar timetable as in the United States, with a 2016 guideline recommending that all infants be introduced to peanuts and eggs in the first year of life, regardless of allergy risk factors. A cross-sectional study found that the percentage of Australian infants who consumed eggs by age 6 months increased from 25% in 2007-2011 to 58% in 2018-2019, with 89% consuming eggs by age 12 months. A recent study by the same research team found that adjusted egg allergy prevalence decreased from 9.2% in 2007-2011 to 7.6% in 2018-2019. The prevalence of egg allergy in infants with eczema in the first 6 months of life also decreased from 34.6% to 21.9%.

In an accompanying editorial, Drs. Aaron Carroll and Ron Keren frankly assessed the harms of the AAP’s and other consensus guidelines that had incorrectly advised parents and guardians against early introduction of eggs in a misguided attempt to prevent allergies:

For years, pediatric guidelines in multiple countries told parents to do something that may have increased the risk of the very outcome they feared most. The deeper problem was not that strong evidence had been misinterpreted; it was that strong evidence did not yet exist. Committees faced a plausible theory, rising anxiety, and pressure to give families an answer. Unfortunately, they gave one with more confidence than the data could support.

The lesson that clinicians and expert panels should learn from this humbling experience, Carroll and Keren argued, is to avoid making strong recommendations based on weak or no evidence:

The field issued recommendations that outran the evidence, and families lived with the consequences. We owe families an honest accounting of that. And we owe it to the next generation of patients to hold ourselves to a higher standard—one that includes evidence grading so families understand the degree of certainty behind a recommendation, mandatory reassessment at regular intervals, and a commitment to funding the trials that can fill evidentiary gaps before guidance is issued rather than decades after.

In a 2023 American Family Physician article on food allergies, a key practice recommendation with an A evidence rating (consistent, good-quality patient-oriented evidence) stated that “early introduction of peanuts, cow’s milk, wheat, and cooked eggs between four and six months of age decreases the risk of developing food allergies.” According to a 2018 Cochrane review, children with egg allergies can be desensitized with oral immunotherapy (“daily, steadily increasing doses of egg protein over an extended period of time”), but 75% will experience allergy-related adverse effects, 8.4% of them serious enough to require medication.

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This post first appeared on the AFP Community Blog.