Treating children with cholesterol medication. Did the AAP strike a nerve?

by James Hubbard, M.D., M.P.H.

A few months back, the American Academy of Pediatrics (AAP) recommended drugs for some children to lower cholesterol.  Outrage, controversy and indignation followed.  Apparently this reaction took the AAP by surprise.  I am not sure why.

Authors of an opinion piece called “Storm Over Statins: The Controversy Surrounding the Pharmagologic Treatment of Children” take a look at this dilemma in the Sept. 25, 2008, issue of the NEJM.

They write:

The recommendation to use statins in childhood seems to havehit a collective nerve, perhaps awakening us to the fuller implicationsof the obesity epidemic. It’s one thing to treat the rare childwho has an inherited defect in cholesterol metabolism and quiteanother to extend treatment to children who are at risk forcardiovascular disease because of modifiable lifestyle factors.

They seem to be asking, are we opening a pandora’s box?  Will we start treating kids with adult blood pressure medicines, preventive aspirin or insulin sensitizers when the real culprit is obesity?

They propose fighting the underlying problem with public health measures.

  • regulating food marketing to children
  • improvingthe quality of nutrition at school
  • promoting physical activityat school and elsewhere
  • providing greater funding for obesityprevention and treatment programs

I definitely believe in their second recommendation, and the government (if they can afford it) has been known to alter public opinion (on tobacco, not so much on drugs).

However, the long-term solution has to be parent involvement, like offering tasty food alternatives and keeping the sugary cereal and junk food out of the house.  Without this, all other efforts are doomed to fail.

I think the AAP did us all a favor by bringing this issue to the forefront, implicitly stating: “Parents, we have a serious problem and an active solution is required.  You can take steps to fix it without medications but, if you don’t, we have will start treating the risk factors we think necessary to prevent future disease in these innocents.”  Parents should be indignant and take this as call-for-action.

There is another good blog on this journal article at the Wall Street Journal’s Healthblog, where I got the idea for this one.

What is your view? Is this an over-hyped problem?  Should the government become involved?  What about medical involvement?  What steps are you taking?

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2 Responses to “Treating children with cholesterol medication. Did the AAP strike a nerve?”

  1. Dan Says:

    Facts Believed to be Associated With All Statin Medications:

    Adverse events associated with the statin class of pharmaceuticals are thought to occur more often than they are reported- with high doses of statins prescribed to patients in particular. However, ince this class of drugs has existed for use for over 20 years, statins are considered safe and effective for enhancing the clearance of LDL noted to be elevated in the lipid profiles of patients.
    Additionally, there is no reduction in cardiovascular morbidity or mortality, as well as an increase in a person’s lifespan, if one is on any particular statin medication for their lipid management over another, others have concluded. So caution should perhaps be considered if one chooses to prescribe such a drug for a patient if they are absent of dyslipidemia to a significant degree, or are under the belief that one statin medication provides a greater cardiovascular benefit over another. In other words, the health care provider should be assured that any statin therapy for their patients is considered reasonable and necessary if the LDL in their patients need to be reduced perhaps at this time with the evidence that exists regarding statins.
    Abstract etiologies for those who choose to prescribe statin drugs on occasion for reasons not indicated by these statin drugs- such as reducing CRP levels, or for Alzheimer’s treatment, or anything else not involved with LDL reduction may not appropriate prophylaxis at this point for any patient. All other benefits that appear to have favorable effects in such areas are speculative at this point, and require further research for disease states aside from dyslipidemia, according to many.
    Statins as a particular class of drugs that seem to in fact decrease the risk of cardiovascular events significantly, it has been proven. Statins also decrease thrombus formation as well as modulate inflammatory responses (CRP). For those patients with dyslipidemia who are placed on a statin, the effects of that statin on reducing a patient’s LDL level can be measured with the efficacy of the statin after about five weeks of therapy on a particular statin drug. Liver Function blood tests are recommended for those patients on continued statin therapy, and most are chronically taking statins for the rest of their lives to manage their lipid profile in regards to maintaining the suitable LDL level for a particular patient presently.
    Yet some have said that about half of all strokes and heart attacks that do occur are not because of increased cholesterol levels of these patients. Others believe that it is oxidized cholesterol that causes vulnerable plaques to form on coronary arterial walls, which is the catalyst for a heart attack, and that there is no medicinal treatment for the formation or stabilization of these plaques to prevent heart attacks or strokes. Others who promote and support statin medicinal therapy claim that these drugs, do, in fact, stabilize these plaques, and therefore are beneficial.
    As stated previously, in regards to other uses of statins besides just LDL reduction, there is evidence to suggest that statins have other benefits besides lowering LDL, such as reducing inflammation (CRP) with patients on statin therapy, those patients with dementia or Parkinson’s disease may benefit from statin medication, as well as those patients who may have certain types of cancer or even cataracts. Yet again, these other roles for statin therapy have only been minimally explored, comparatively speaking. Because of the limited evidence regarding additional benefits of statins, the drug should again be prescribed for those with dyslipidemia only at this time involving elevated LDL levels as detected in the patient’s bloodstream.

    Yet overall, the existing cholesterol lowering recommendations or guidelines should be re-evaluated, as they may be over-exaggerated upon tacit suggestions from the makers of statins to those who create these current lipid lowering guidelines. This is notable if one chooses to compare these cholesterol guidelines with others in the past. The cholesterol guidelines that exist now are considered by many health care providers and experts to be rather unreasonable, unnecessary, and possibly detrimental to a patient’s health, according to others. Yet statins are beneficial medications for those many people that exist with elevated LDL levels that can cause cardiovascular events to occur because of this abnormality. What that ideal LDL level is may have yet to be empirically determined.
    Finally, a focus on children and their lifestyles should be amplified so their arteries do not become those of one who is middle-aged, and this may prevent them from being candidates for statin therapy now and in the future, regarding the high cholesterol issue.
    Dietary management should be the first consideration in regards to correcting lipid dysfunctions,

    Dan Abshear

  2. James Hubbard, M.D., M.P.H. Says:

    Dan,
    Thanks for the comment. I limit statins to trying to keep LDL cholesterol under 100. Diet and exercise are always a must. Some well-known and excellent physicians are more liberal in their usage, but I await more studies to make sure it is not one of those “too good to be true” scenerios. If we overuse it, there will be more publicity on more side effects just by a numbers game, if nothing else.

    I know there are exceptions but I have not given up on kids keeping weight down with diet and exercise.

    Great blog you have.

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