Kids and Statins: A DILEMMA: TO TREAT OR NOT TO TREAT

20 Feb
2010

Today, health care providers must ask themselves these questions:

  • Should we consider at-risk children for medical management with hypercholesterolemic drugs, particularly the class reputed to be the most effective, the HMG-CoA reductase inhibitors (statins)?
  • Should we recommend only lifestyle modification along with a low-fat or a low-carbohydrate diet and daily vigorous aerobic exercise?
  • Should we do neither—and possibly wait for the manifestation of cardiovascular risks that affect millions of adults yearly?

Certainly, lifestyle changes have little down side, and their benefits extend far beyond the cardiovascular system. Experts debate constantly about the optimal nutritional approach to lowering cholesterol levels and weight. Short-term results have suggested that the low-carbohydrate approach might help to increase weight loss and lower total and low-density lipoprotein-cholesterol (LDL-C) levels. However, meta-analyses of the various popular low-fat and low-carbohydrate nutritional plans reveal little advantage to either when these regimens are extended for one year or greater. This is, in large part, a result of the difficulties in the long-term compliance with these diets. Although the concepts behind them are well intentioned and worthy of consideration, the public in general often sees only the extreme form of them on display. Compliance with lifestyle modifications, including diet and exercise, is discussed later in this article.

Prescribing the optimal exercise program is also an imprecise art, and recommendations for the amount of time that should be devoted to physical activity vary among practitioners. Most health care professionals suggest one hour or more of moderate-intensity exercise on most days of the week. This exercise may include activities resulting in heavy breathing or being able to speak in short sentences upon exertion. However, this is not an evidence-based recommendation by any means. kamagra soft tablets

Because of the scarcity of studies on the safety of statin therapy in older children and adolescents, the known side-effect profile in adults, the unknown long-term effects on growth and development, and the virtual lack of any prospective efficacy studies of cardiac or all-cause mortality and morbidity in children have limited the use of statins in adolescents.

The fundamental question arises: Is coronary artery disease actually present if the individual in question has no symptoms whatsoever? If the answer is “no,” the decision to treat hyper-cholesterolemia in childhood would be an easy one—it would be a resounding “no.”

However, the reality is that our society recognizes that a disease can exist even when an individual is asymptomatic. For example, physicians and nutritionists give nutritional supplements or recommend dietary alterations for newborns when their initial screening reveals a deficiency in a vital enzyme. This practice may successfully prevent serious health consequences later. Hypertensive adults are often completely asymptomatic yet are treated to lower their blood pressure so as to minimize the occurrence of cardiovascular disease. Smoking cessation is a form of treatment of a very significant cardiovascular risk factor years prior to any onset of symptoms. These forms of primary prevention are the most effective tools for treating diseases—by averting their occurrence in the first place.
Thus, identifying a well-researched risk factor, such as elevated cholesterol, should prompt the same philosophical approach to prophylactic treatment. Data collected decades ago from hundreds of Korean War and Vietnam War casualties revealed that coronary atherosclerotic plaques were well formed by the time the soldiers were 20 years of age. Unfortunately, correlative data on dyslipidemia were not available for most of these men. However, the Pathobiological Determinants of Atherosclerosis in Youth (PDAY) report and the Bogalusa studies demonstrated a direct correlation of dyslipidemia and coronary artery plaque formation in 15- to 34-year-olds.

Studies utilizing intracardiac ultrasound in vivo demonstrate the presence of increased intimal thickness in dyslipidemic older children (above 10 years of age) and adolescents. Further diagnostic modalities, such as electron-beam CT, demonstrate significantly increased coronary calcium scores in individuals with familial hypercholesterolemia. The higher the calcium levels, the higher the correlation with more advanced coronary artery disease.

So, back to our earlier question: should we treat all children who have hypercholesterolemia? Unfortunately, the answer is not simple. The difficulties may lie in the following: screening, compliance, and medical management.
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