Kids and Cholesterol Meds

[Turtle]

Dr. Steve, few young people have a high ten year risk of CHD but they may well have a very high lifetime risk of an atherosclerotic event. At what point does one get serious with pharmacological therapy -- right away and totally prevent the disease, or let the disease get established and then treat with the hopes of preventing the established disease to cause a clinical event. Do ten year risk assessment tools have any real use in young people or are they a disservice?

Please use the following case as a base for your answer: 22 yo male, who is a senior in college with a history of dyslipidemia, ADD (treated with Adderall), and a complaint of palpitations on exertion. He drinks 10-14 beers per week, denies tobacco use and exercises only 1-2 days per week (for maybe 30 minutes per day). His family history reveals his mother and father are in the mid 50s with low HDL-C between 25 and 32 mg/dL. His height is 5'10" and weight 165 lbs.

His lipid profile revealed a TC of 139, LDL-C of 75, TG of 174, VLDL-C of 34 and an HDL-C of 29. The non-HDL-C calculates to 110 mg/dL. The TG/HDL-C was: 4.1. The lipoprotein testing using the NMR LipoProfile and the results are:


LDL-P 1340
Small LDL-P 1111
LDL particle size is small at 20.1
Large HDL-P 3.1
Large VLDL 8.5

He was started on Niaspan 1G QID and was noncompliant.


Also with HMGCOa Reductace Inhibitors now beeing used in childred, is there real long term risk?

[Dr Steve]

Dr. Steve, few young people have a high ten year risk of CHD but they may well have a very high lifetime risk of an atherosclerotic event. At what point does one get serious with pharmacological therapy -- right away and totally prevent the disease, or let the disease get established and then treat with the hopes of preventing the established disease to cause a clinical event. Do ten year risk assessment tools have any real use in young people or are they a disservice?

Please use the following case as a base for your answer: 22 yo male, who is a senior in college with a history of dyslipidemia, ADD (treated with Adderall), and a complaint of palpitations on exertion. He drinks 10-14 beers per week, denies tobacco use and exercises only 1-2 days per week (for maybe 30 minutes per day). His family history reveals his mother and father are in the mid 50s with low HDL-C between 25 and 32 mg/dL. His height is 5'10" and weight 165 lbs.

His lipid profile revealed a TC of 139, LDL-C of 75, TG of 174, VLDL-C of 34 and an HDL-C of 29. The non-HDL-C calculates to 110 mg/dL. The TG/HDL-C was: 4.1. The lipoprotein testing using the NMR LipoProfile and the results are:


LDL-P 1340
Small LDL-P 1111
LDL particle size is small at 20.1
Large HDL-P 3.1
Large VLDL 8.5

He was started on Niaspan 1G QID and was noncompliant.


Also with HMGCOa Reductace Inhibitors now beeing used in childred, is there real long term risk?


What is this, some kind of board review question? Jeez.

You bring up a serious point or two, though...kids in this country are not only fat shits, but are getting atherosclerotic plaques (hardening of the arteries) at an earlier age.

I'm just gonna have to go academic on yo' ass:

J Clin Endocrinol Metab. 2008 Aug 12. [Epub ahead of print]

Recognition and Management of Dyslipidemia in Children and Adolescents.
Kwiterovich PO Jr.

Lipid Research Atherosclerosis Division, Departments of Pediatrics and Medicine,
The Johns Hopkins Medical Institutions, 550 North Broadway, Suite 310, Baltimore,
MD 21205.

Context. Cardiovascular disease (CVD) remains the number one cause of death in
the USA. The origins of atherosclerosis and CVD begin in childhood. Dyslipidemia
and obesity are endemic in American youth and require urgent action.

Evidence Acquisition.
A detailed literature search from 1985 to 2008 was performed using
PubMed and subsequent reference searches of retrieved articles.

ok, this is a "meta analysis", which means it's a combination of a bunch of studies to try to make a larger sample size and give some guys who didn't actually do any research on the subject a chance to publish in a respected medical journal.

Selection of
included articles was based on rigor of scientific design, adequate sample size,
quality of the data, statistical analysis and hypothesis testing.

Evidence Synthesis. CVD risk factors in children predict pathologic lesions of
atherosclerosis in young adults, and their clinical manifestations, as judged by
carotid intima medial thickness, coronary artery calcium, or brachial
flow-mediated dilatation. About half the offspring of a parent with premature CVD
have a primary dyslipidemia. However, use of family history to identify such
youth will miss the majority of children with dyslipidemia. Treatment of
dyslipidemia starts with a low fat diet supplemented with water-soluble fiber,
plant stanols and plant sterols, weight control and exercise. Drug therapy with
inhibitors of hydroxymethylglutaryl CoA reductase, bile acid sequestrants, and
cholesterol absorption inhibitors, can be considered in adolescents with a
positive family history of premature CVD and a LDL-C > 160 mg/dL. Such dietary
and drug therapy appears safe and efficacious and is likely to retard
atherosclerosis.

Conclusions. Early identification and treatment of youth at risk
for early atherosclerosis will require an integrated assessment of predisposing
CVD risk factors and a comprehensive universal screening and treatment program.

Whew. Long term data is missing when it comes to pediatrics...they've studied it for 3 and 4 years, but I couldn't find any longer studies; these drugs were found to be safe for these time periods. If you can find a longer-term study somewhere, I'd love to check it out. It's past my bedtime and I can't find one at the moment. :-)

your pal,



steve

ps: if a tool tells me i have a .05% chance of having a complication over the next 10 years, but I'm 5 and I'm guaranteed to have a 90% chance of that same compication when I'm 50, AND I could prevent it safely by making modifications in my lifestyle and perhaps taking medication NOW, then i'd say the 10 year calculator is full of shit and really doesn't apply to me. Honestly, I don't know if we can say that about framingham data at this time...we need way more long-term studies in kids to see if we really should be treating them with drugs early on. If we could just stop shoving twinkies, ding dongs, and chicken McFuckit's into their craws, all of this might be completely unecessary except for the kid with the genetic abnormality.

[Turtle]

What is this, some kind of board review question? Jeez.

You bring up a serious point or two, though...kids in this country are not only fat shits, but are getting atherosclerotic plaques (hardening of the arteries) at an earlier age.

I'm just gonna have to go academic on yo' ass:

J Clin Endocrinol Metab. 2008 Aug 12. [Epub ahead of print]

Recognition and Management of Dyslipidemia in Children and Adolescents.
Kwiterovich PO Jr.

Lipid Research Atherosclerosis Division, Departments of Pediatrics and Medicine,
The Johns Hopkins Medical Institutions, 550 North Broadway, Suite 310, Baltimore,
MD 21205.

Context. Cardiovascular disease (CVD) remains the number one cause of death in
the USA. The origins of atherosclerosis and CVD begin in childhood. Dyslipidemia
and obesity are endemic in American youth and require urgent action.

Evidence Acquisition.
A detailed literature search from 1985 to 2008 was performed using
PubMed and subsequent reference searches of retrieved articles.

ok, this is a "meta analysis", which means it's a combination of a bunch of studies to try to make a larger sample size and give some guys who didn't actually do any research on the subject a chance to publish in a respected medical journal.

Selection of
included articles was based on rigor of scientific design, adequate sample size,
quality of the data, statistical analysis and hypothesis testing.

Evidence Synthesis. CVD risk factors in children predict pathologic lesions of
atherosclerosis in young adults, and their clinical manifestations, as judged by
carotid intima medial thickness, coronary artery calcium, or brachial
flow-mediated dilatation. About half the offspring of a parent with premature CVD
have a primary dyslipidemia. However, use of family history to identify such
youth will miss the majority of children with dyslipidemia. Treatment of
dyslipidemia starts with a low fat diet supplemented with water-soluble fiber,
plant stanols and plant sterols, weight control and exercise. Drug therapy with
inhibitors of hydroxymethylglutaryl CoA reductase, bile acid sequestrants, and
cholesterol absorption inhibitors, can be considered in adolescents with a
positive family history of premature CVD and a LDL-C > 160 mg/dL. Such dietary
and drug therapy appears safe and efficacious and is likely to retard
atherosclerosis.

Conclusions. Early identification and treatment of youth at risk
for early atherosclerosis will require an integrated assessment of predisposing
CVD risk factors and a comprehensive universal screening and treatment program.

Whew. Long term data is missing when it comes to pediatrics...they've studied it for 3 and 4 years, but I couldn't find any longer studies; these drugs were found to be safe for these time periods. If you can find a longer-term study somewhere, I'd love to check it out. It's past my bedtime and I can't find one at the moment. :-)

your pal,



steve

ps: if a tool tells me i have a .05% chance of having a complication over the next 10 years, but I'm 5 and I'm guaranteed to have a 90% chance of that same compication when I'm 50, AND I could prevent it safely by making modifications in my lifestyle and perhaps taking medication NOW, then i'd say the 10 year calculator is full of shit and really doesn't apply to me. Honestly, I don't know if we can say that about framingham data at this time...we need way more long-term studies in kids to see if we really should be treating them with drugs early on. If we could just stop shoving twinkies, ding dongs, and chicken McFuckit's into their craws, all of this might be completely unecessary except for the kid with the genetic abnormality.

Bile acid sequestrants! Stop you may as well ask them to eat sawdust.

There was a pediatric cardiologist on XM 153 last week talking about the use of statins in children, the vast majority of whom are type two diabetics and lead sedentary lifestyles. The data on statins (4S and HPS with simvastatin) is great, but there is a huge difference between putting a 45-50 year old man on a statin for the next 30 years and putting a ten year old boy on a statin for the next 70 years. Additionally these kids may very well wind up on an ACE inhibitor, fibrates and many other medecations at a very young age. In your opinion do you think these kids will end up having to deal with renal or hepatic dysfunction as adults?

[Dr Steve]

There was a pediatric cardiologist on XM 153 last week talking about the use of statins in children, the vast majority of whom are type two diabetics and lead sedentary lifestyles. The data on statins (4S and HPS with simvastatin) is great, but there is a huge difference between putting a 45-50 year old man on a statin for the next 30 years and putting a ten year old boy on a statin for the next 70 years. Additionally these kids may very well wind up on an ACE inhibitor, fibrates and many other medecations at a very young age. In your opinion do you think these kids will end up having to deal with renal or hepatic dysfunction as adults?

That's absolutely a concern, isn't it? In the end, prevention is the key. Our high carbohydrate, low activity lifestyle is not conducive to longevity. Make your kids eat vegetables, lay off the fast food, and get them outside to play. Our bodies are adapted to a low carbohydrate diet and running away from sabertooth tigers, not XBox 360 (ok, I play "MASS EFFECT" and "CoD4" like everyone else...my gamertag is Darth Scratchy if anyone wants to play) and french fries.

I would be very concerned about giving some poor kid a statin for 70 years, though if we had 70 year data it'd make me feel a lot better about it. Statins haven't even been around for 70 years, so this kind of timeline data is impossible to have.

In the end, it's a decision analysis game: if you have a 2/3 chance of increasing your life by 20 years, but a 1/3 chance of dying 10 years early, what do you do? The problem here is that we don't even have the fractions to plug in to try to make a rational decision.