Since 1992 we have known that children and adolescents with high lipids needed counseling on diet to reduce their levels over a 6-12 month period. But what if diet didn’t work. Should we put them on medications?

A new American Heart Association (AHA) statement says yes! The 1992 position did recommend certain medications for children. The medications they recommend tend to bind cholesterol in the intestines and prevent the absorption of cholesterol. The problem is that these resins are poorly tolerated and there is terrible compliance with children. Besides, the resins really did not lower cholesterol enough.

Now it is recommended that children with familial (genetic or inherited) hypercholesterolemia be given statins (Lipitor, Zocor, Mevacor, Vytorin, etc) to lower the cholesterol. So why haven’t we always given children these very effective drugs? These drugs have been associated with elevated liver enzymes and we would be starting the drugs at an early age for possibly lifelong therapy. While we know these drugs are safe over short periods of time, the concern is what happens after decades of use.

It is because of these concerns that we still do not give every child with elevated cholesterol a statin drug. Here are the recommendations:

Screening: any child with a family history of heart disease under age 55or cholesterol over 240 or children that are overweight.
Further evaluation or treatment: if LDL is borderline (110-129) or high (over 130) or with a low HDL.
Initial treatment: 6-12 months of low fat diet with increased physical activity.
Drug therapy: males age 10 or females after menarche if, after aggressive dietary management, the LDL remains 190 or higher (lower if there is a strong family history or two or more risk factors such as low HDL, overweight, diabetes, hypertension, or elevated C-reactive protein or homocysteine) in males or 160 in females.
First-line drug: It use to be the resins noted above, now it is a statin.
Target: at least an LDL of 130 and ideally 110.

By setting the bar this high to begin treatment we are fairly confident that we are getting mainly children with familial hypercholesterolemia. The incidence of this disease is about 1 in 500. Once therapy is started your doctor will monitor liver enzymes at 4 weeks, 8 weeks and 3 months. If the liver values go up then we stop the therapy until the values are back to normal.

That’s it for this week. Play hard, eat wise and I won’t need to see you at my office.