Several years ago, Dr. Antonio
Gotto, noted lipid researcher, jokingly suggested putting
statins in the drinking water. While we are not quite there yet, we are closer to that facetious goal with the latest recommendations from the American Academy of Pediatrics. Go
here to read their paper.
I found their recommendations more than a bit surprising in light of the following: 1) an apparent reversal from their earlier pronouncements, 2) the lack of evidence presented in their paper addressing the issues of long term safety and long term efficacy regarding decrease in clinical coronary artery disease events. The emphasis on surrogate measurements on which they had to rely given the paucity of long term outcome data is in contrast to the bad press surrogate measurements have recently received in diabetes drug trials.
So what group of children should be considered for prescription drug therapy.Here is what the
AAP said:
- For patients 8 years and older with an LDL concentration of
190 mg/dL (or 160 mg/dL with a family history of early heart disease or 2 additional risk factors present or 130 mg/dL if diabetes mellitus is present), pharmacologic intervention should be considered. The initial goal is to lower LDL concentration to <160> 110 mg/dL may be warranted when there is a strong family history of CVD, especially with other risk factors including obesity, diabetes mellitus, the metabolic syndrome, and other higher-risk situations.
After you read the Pediatric association's argument for their position go here and read what is ,in my opinion, a much more reasoned and scholarly
assessment of this general issue by the prolific Sandy
Szwarc.(Thanks to Dr. Wes for that reference).
1 comment:
I agree with you that the AAP guidelines are too aggressive and that we have no proof that starting treatment in childhood or adolescence will prevent heart attacks, or will prevent more heart attacks than starting later. The AHA guidelines that were issued in March 2007 were a little more reasonable. I would like to clarify a couple of points, though:
1. The AAP guidelines, unlike the AHA guidelines, do not specify that statins should be first-line therapy (i.e., instead of ezetimibe or bile acid sequestrants). Personally, I feel that if you are going to treat someone, you should treat them with something that works. Therefore, I view the AHA guidelines as superior on that point.
2. There are some high risk kids, such as kids with heterozygous familial hypercholesterolemia, who I think it would not be unreasonable to treat starting in adolescence, especially in the case of boys.
3. For the small group of kids who reasonably could be treated with statins, a low or moderate dose should be used in virtually all cases.
4. It goes without saying that children with homozygous FH (1/million) need to be treated aggressively as soon as they are diagnosed.
Marilyn Mann
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