Kids and Cholesterol-Lowering Drugs
In July, the American Academy of Pediatrics (AAP) issued new guidelines on management of high cholesterol in children. The release of the guidelines provoked a storm of controversy. I have a special interest in this topic because my 15-year-old daughter has a genetic disorder
called heterozygous familial hypercholesterolemia (heFH) that causes very high LDL (“bad”) cholesterol from birth. Persons with heFH are at high risk of early heart attacks.
For example, my husband’s maternal grandfather died of a heart attack at 35, his maternal uncle died of a heart attack at 40, and his mother had a nonfatal heart attack at 58. HeFH is fairly common, occurring in approximately 1/500 people worldwide, and cannot be controlled with diet and exercise. Imaging tests of children with heFH have shown them to have accelerated atherosclerosis, as compared to their unaffected siblings, by age 12.
There have been a number of clinical trials of statins in children with heFH, with good results. However, we really do not know whether treating individuals with heFH starting in childhood prevents more heart attacks than waiting until adulthood. Consequently, while there is a general consensus in the medical community that all adults with heFH should be treated, with statins being the first-line therapy, there is less consensus on whether and how to treat children. Areas of controversy include the appropriate age to start, whether to treat girls as well as boys, how aggressively to treat, and what medications to use.
If treating kids with heFH is controversial, it is not surprising that many people disagree with the idea of treating kids with high cholesterol due to obesity, inactivity, and poor diet. Today’s New England Journal of Medicine contains a commentary on the AAP guidelines and the associated controversy by pediatricians Sarah de Ferranti and David S. Ludwig, in which the authors point out that
. . . [t]he recommendation to use statins in childhood seems to have hit a collective nerve, perhaps awakening us to the fuller implications of the obesity epidemic. It’s one thing to treat the rare child who has an inherited defect in cholesterol metabolism and quite another to extend treatment to children who are at risk for cardiovascular disease because of modifiable lifestyle factors. At present, we do not know how many children or adolescents will meet the criteria for statin treatment because of the effects of obesity, poor diet, or physical inactivity. . . . Regardless of how many additional children may receive statin treatment under these new guidelines, the broader, more important question is whether we intend to treat pediatric obesity with an ever-increasing array of powerful adult drugs . . . . Once this door has been opened, the pharmaceutical industry will happily walk through it. Instead of fewer advertisements for junk food, are we destined to see new commercials promoting the use of cholesterol-lowering medications in children? The intense media coverage of the new statin policy may have shined a light on the profound cultural disconnect between our willingness to treat disease with drugs and our reluctance to institute preventive public health measures. These measures would include regulating food marketing to children, improving the quality of nutrition at school, promoting physical activity at school and elsewhere, and providing greater funding for obesity prevention and treatment programs.
I wholeheartedly agree with the authors’ call for these preventive public health measures. In a future post, I plan to discuss the specifics of the AAP guidelines, and where I think they fall short.
Thanks to Marylin for the post. 🙂