Drug Therapy of Hypercholesterolaemia in Children and Adolescents

Abstract

Cardiovascular disease (CVD) remains the leading cause of death and morbidity in the world. The origins of atherosclerosis and subsequent CVD begin in childhood. In order to prevent CVD, children and adolescents at high risk for premature atherosclerosis should be identified and treated as early as possible. Hypercholesterolaemia is a major risk factor for atherosclerosis. Childhood hypercholesterolaemia can be either primary, due to hereditary disorders such as familial hypercholesterolaemia (FH) and familial combined hyperlipidaemia (FCHL), or secondary due to obesity, diabetes mellitus or nephrotic syndrome. Current guidelines suggest screening for hypercholesterolaemia between the ages of 2 and 10 years. Treatment strategies include lifestyle interventions involving dietary changes and increased physical activity. If these interventions are insufficient in lowering serum low-density lipoprotein cholesterol (LDL-C) levels, pharmacological therapy should be considered from the age of 8 years. Currently, statins are the preferred initial pharmacological therapy and have proven to be both efficient and well tolerated. However, long-term data on safety, and regular monitoring of those patients treated with statins, are still required, because in children with primary hypercholesterolaemia, treatment should be continued for life.

Integrated guidance on the care of familial hypercholesterolaemia from the International FH Foundation

“…Although systematic reviews confirm the safety of currently employed statins in children [146,147], the long-term sequelae of high intensity statin regimens are unknown. Good longterm data on the safety of statins started early in life are therefore required [148,149], emphasizing the need to establish a suitable international registry [150]. The plasma LDL-cholesterol targets for children aged 8 to 10 years should be < 4.0 mmol/L and for those older than 10 years < 3.5 mmol/L [8,19,20,22,65,66,73,145,148].…”

“…Children with a particularly adverse family history of CHD and other major risk factors could be considered for earlier treatment with statins [8,19,43,44,65,73,145]; this may be especially important in boys [1,3,43,44]. If goals are not achieved, consideration should be given to the addition of ezetimibe or bile acid sequestrants [8,19,65,66,148,149]. Balancing the need to achieve LDLcholesterol targets with possible side effects should be considered in individualizing drug therapy [148,149].…”

“…If goals are not achieved, consideration should be given to the addition of ezetimibe or bile acid sequestrants [8,19,65,66,148,149]. Balancing the need to achieve LDLcholesterol targets with possible side effects should be considered in individualizing drug therapy [148,149]. Children with homozygous FH should be referred to a specialist centre: medications should be initiated at diagnosis, higher potency statins in combination with other agents will be required, and apheresis must be considered [8,19,20,22,61,65,73,152].…”

“…Prior to initiating statin therapy, plasma aminotransferases, CK, glucose, and creatinine should be measured [8,19,20,22,65,148,149]. After starting therapy, weight, growth, physical and sexual development should be monitored.…”

Diagnóstico y tratamiento de las dislipidemias en niños y adolescentes: Recomendaciones de la Rama de Nutrición de la Sociedad Chilena de Pediatría

“…disminuye c-ldl (20-25%), tg (8-10%) y aumenta c-hdl (1-4%) 40 . combinado con simvastatina, reduce c-ldl hasta 50-60% 41 . en general es bien tolerado y está aprobado por la Fda como tratamiento de primera línea en niños > 10 años, dosis: 5-10 mg/ barja S. y cols.…”