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According to 1992 national guidelines on cholesterol, children and adolescents with abnormal lipids should follow a fat-and cholesterol-restricted diet aimed at normalizing lipid values over 6–12 months.1 But what if such dietary management fails to sufficiently improve their lipid profiles? Physicians should consider prescribing statins for these young people if they have familial hypercholesterolemia, suggests a new American Heart Association (AHA) statement.2
Brian W. McCrindle, MD, MPH, senior scientist with Child Health Evaluative Sciences and staff cardiologist at The Hospital for Sick Children, both affiliated with University of Toronto, and colleagues arrived at this recommendation after assessing results from clinical trials in children and adolescents with familial hypercholesterolemia as well as from statin studies in adults. They also factored in evidence indicating that atherosclerosis begins during childhood.
Data supporting the AHA recommendations have emerged since the 1992 release
of the National Cholesterol Education Program (NCEP) Expert Panel on Blood
Cholesterol Levels in Children and
Adolescents.2 NCEP
recommends bile acid-binding resins, such as cholestyramine (Questran,
Bristol-Myers Squibb), colestipol (Colestid, Pfizer), and colesevelam
(WelChol, Sankyo), as the initial drug for children 
10 years (or after
menarche for girls) who require lipid-lowering drug
therapy.2
Yet, McCrindle says, "It is well documented that the resins are very poorly tolerated, with very poor compliance in children." Furthermore, bile acid-binding resins don't lower lipids enough to significantly reduce children's lipid profiles.2,3
In comparison, statins appear to more effectively lower total and LDL cholesterol in children with familial hypercholesterolemia.3 But the idea of initiating statin therapy in children may give some clinicians pause: The drug has been associated with elevated liver enzymes and increased creatine kinase (CK) levels, and these drugs would be instituted at a young age, presumably for lifelong therapy, says Robert H. Eckel, MD, professor of medicine at University of Colorado at Denver and Health Sciences Center and director of University Hospital's Lipid Clinic. (Eckel, a past president of AHA, notes that he had no role in the development of these AHA guidelines.)
"The evidence is good to indicate that statins are safe over short intervals," Eckel says. "The concerns relate to potential downside effects that might occur decades later."
EARly lIpIDS SCREENING
Step one is to identify those children needing lipids intervention. NCEP suggests selective lipids screening for children and adolescents with a family history of early coronary heart disease or high cholesterol.1–3 But screening based on family history may miss 30–60% of young patients with elevated lipids, according to a recent evidence synthesis by the Agency for Healthcare Research and Quality.3
The AHA modifications place a greater emphasis on assessing cardiometabolic risk. For instance, a child with obesity should undergo lipids screening regardless of family history, McCrindle says.
And, in spite of reservations about prescribing statins to youth, Eckel acknowledges the importance of early identification of cardiovascular risk. "We know atherosclerosis does occur in young people."
In addition to plotting height and weight, calculating body mass index (BMI), and taking family history as part of well-child care, McCrindle suggests that primary care physicians also plot BMI and update family history over time—then use all these factors to decide how aggressively to address elevated lipids.
"A lot of overweight kids will have lipid abnormalities," McCrindle says, "but not to the magnitude that will require drug therapy."
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WHEN TO USE STATINS
McCrindle's group does not advocate widespread use of medications to treat lipid abnormalities associated with childhood obesity.2
"The bar is set rather high, so the vast majority of [young] people who meet the criteria for starting drugs will have familial hypercholesterolemia," McCrindle says. The incidence of familial hypercholesterolemia in the U.S., Canada, and Europe is 1 in 500.3
Clinicians considering drug therapy in dyslipidemic children should follow NCEP criteria for drug initiation (see chart), AHA recommends. Additionally, the new AHA recommendations call for clinicians to:
Patients with laboratory abnormalities or adverse reactions should cease therapy until parameters return to normal. Among patients with no adverse reactions or abnormal laboratory values who have not achieved target LDL cholesterol levels, clinicians may double the statin dosage, with monitoring, and may continue adjusting the dosage until the patient achieves the target LDL or shows evidence of toxicity.
McCrindle and his colleagues suggest recommendations for statin therapy,
such as these, be subject to ongoing study and modification. 
Diet Advice Makes a Difference
Ideally, children at risk for diet-related medical problems should see a registered dietitian for assessment of eating patterns, says Roberta H. Anding, RD, American Dietetic Association spokesperson and pediatric dietitian at Texas Children's Hospital in Houston.
But, Anding notes, in 5 minutes a busy physician can suggest dietary changes to help children lower their lipid levels:
Footnotes
The full American Heart Association scientific statement on drug therapy for children and adolescents with high-risk lipids profiles is available at http://circ.ahajournals.org/cgi/content/full/115/14/1948.
References
2. McCrindle BW, Urbina EM, Dennison BA, et al.: Drug therapy of
high-risk lipid abnormalities in children and adolescents: A scientific
statement from the American Heart Association Atherosclerosis, Hypertension,
and Obesity in Youth Committee, Council of Cardiovascular Disease in the
Young, with the Council on Cardiovascular Nursing.
Circulation 115:1948–1967, 2007.
3. Agency for Healthcare Research and Quality: Evidence synthesis number 46: Screening for lipid disorders in children and adolescents: Systematic evidence review for the U.S. Preventive Services Task Force. AHRQ Publication No. 07-0598-EF-1, July 2007. Available online at www.ahrq.gov/clinic/uspstf07/chlipid/chlipidsyn.pdf. Accessed August 16, 2007.
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