Do We Need to Assess the Effect of Treatment Withdrawal?

See related article, pages 2652–2657 .In this issue of Stroke , Colivicchi et al observe the impact of statin discontinuation after an ischemic stroke1: they suggest this phenomenon is not only frequent, but also associated with a significant increase of total mortality. Usually considered as secondary, the question of treatment withdrawal becomes more and more important because of: (1) the regular increase of the number of treatments with a convincing demonstration of preventive effects; (2) the general extension of life expectancy in high income countries, which explains both a dramatic increase in the numbers of elderly, and of the length of exposure to treatment far beyond that over which their effect has been estimated; (3) the high prevalence of treatment discontinuation, as illustrated by Colivicchi.1If treatment effect were constant over time, we would expect similar effects across various ages, which is not the case for blood pressure–lowering drugs. A significant 10% to 15% decrease in total mortality has been associated with these treatments in hypertension around 60 years of age, with either diuretics2 or ACE-inhibitors3 as first-line drugs. Preliminary results (both from a subgroup meta-analysis4 and from a specific pilot trial5 …