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Kavey REW. Myopathy in Statin-Treated Children and Adolescents: A Practical Approach. Curr Atheroscler Rep 2024:10.1007/s11883-024-01239-x. [PMID: 39316353 DOI: 10.1007/s11883-024-01239-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/05/2024] [Indexed: 09/25/2024]
Abstract
PURPOSE OF REVIEW This paper reviews the existing literature on statin-related myopathy in children and adolescents, to inform development of a practical management approach. RECENT FINDINGS Reports of statin treatment in the pediatric population revealed no evidence of muscle pathology, with asymptomatic elevation of creatine kinase(CK) levels and symptoms of muscle pain without CK elevation seen equally in subjects and controls in RCTs. By contrast, rare cases of rhabdomyolysis have now been documented in statin-treated children; this serious problem had never been previously reported. Statin-induced myopathy is rare in childhood so routine monitoring of CK levels is unnecessary in asymptomatic patients, reserved for those with muscle pain. Rare case reports of rhabdomyolysis in statin-treated children and adolescents suggest that parent and patient education on symptoms of adverse statin effects should include immediate physician contact with the appearance of dark urine, with or without muscle pain.
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Affiliation(s)
- Rae-Ellen W Kavey
- University of Rochester Medical Center, 1475 East Avenue, Rochester, NY, 14610, USA.
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Fularski P, Hajdys J, Majchrowicz G, Stabrawa M, Młynarska E, Rysz J, Franczyk B. Unveiling Familial Hypercholesterolemia-Review, Cardiovascular Complications, Lipid-Lowering Treatment and Its Efficacy. Int J Mol Sci 2024; 25:1637. [PMID: 38338916 PMCID: PMC10855128 DOI: 10.3390/ijms25031637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Revised: 01/19/2024] [Accepted: 01/26/2024] [Indexed: 02/12/2024] Open
Abstract
Familial hypercholesterolemia (FH) is a genetic disorder primarily transmitted in an autosomal-dominant manner. We distinguish two main forms of FH, which differ in the severity of the disease, namely homozygous familial hypercholesterolemia (HoFH) and heterozygous familial hypercholesterolemia (HeFH). The characteristic feature of this disease is a high concentration of low-density lipoprotein cholesterol (LDL-C) in the blood. However, the level may significantly vary between the two mentioned types of FH, and it is decidedly higher in HoFH. A chronically elevated concentration of LDL-C in the plasma leads to the occurrence of certain abnormalities, such as xanthomas in the tendons and skin, as well as corneal arcus. Nevertheless, a significantly more severe phenomenon is leading to the premature onset of cardiovascular disease (CVD) and its clinical implications, such as cardiac events, stroke or vascular dementia, even at a relatively young age. Due to the danger posed by this medical condition, we have investigated how both non-pharmacological and selected pharmacological treatment impact the course of FH, thereby reducing or postponing the risk of clinical manifestations of CVD. The primary objective of this review is to provide a comprehensive summary of the current understanding of FH, the effectiveness of lipid-lowering therapy in FH and to explain the anatomopathological correlation between FH and premature CVD development, with its complications.
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Affiliation(s)
- Piotr Fularski
- Department of Nephrocardiology, Medical University of Lodz, ul. Zeromskiego 113, 90-549 Lodz, Poland
| | - Joanna Hajdys
- Department of Nephrocardiology, Medical University of Lodz, ul. Zeromskiego 113, 90-549 Lodz, Poland
| | - Gabriela Majchrowicz
- Department of Nephrocardiology, Medical University of Lodz, ul. Zeromskiego 113, 90-549 Lodz, Poland
| | - Magdalena Stabrawa
- Department of Nephrocardiology, Medical University of Lodz, ul. Zeromskiego 113, 90-549 Lodz, Poland
| | - Ewelina Młynarska
- Department of Nephrocardiology, Medical University of Lodz, ul. Zeromskiego 113, 90-549 Lodz, Poland
| | - Jacek Rysz
- Department of Nephrology, Hypertension and Family Medicine, Medical University of Lodz, ul. Zeromskiego 113, 90-549 Lodz, Poland
| | - Beata Franczyk
- Department of Nephrocardiology, Medical University of Lodz, ul. Zeromskiego 113, 90-549 Lodz, Poland
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Bansal N, Kumar S, Brar PC. Update on management of paediatric dyslipidaemia. Curr Opin Endocrinol Diabetes Obes 2023; 30:52-64. [PMID: 36541082 DOI: 10.1097/med.0000000000000794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
PURPOSE OF REVIEW Atherosclerosis and associated cardiovascular risk factors originate in childhood; hence, early management of dyslipidaemia is vital. However, hypercholesterolemia remains untreated or undertreated in many youths. We review current therapies, drugs under investigation and consider potential future directions for the management of paediatric dyslipidaemia to highlight the recent evidence and new therapeutic options for future use. RECENT FINDINGS Cardiovascular disease (CVD) risk factors in childhood, including dyslipidaemia, are associated with CVD risk and clinical CVD events in adulthood. Recent data show that initiation of statin therapy in childhood in children with familial hypercholesterolemia reduces the risk of CVD in adulthood. Several well tolerated and efficacious treatment options have become available in recent times for the management of dyslipidaemia in youth. Many new lipid-lowering drugs are under investigation to widen the available choices. Some of these drugs are now available for use in paediatrics, while some remain targets for future use. SUMMARY We review available treatment options for paediatric dyslipidaemia management, discuss potential limitations and propose future directions. We also acknowledge the need for continued research in paediatrics for optimal paediatric dyslipidaemia management.
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Affiliation(s)
- Nidhi Bansal
- Division of Pediatric Endocrinology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Seema Kumar
- Division of Pediatric Endocrinology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota
| | - Preneet Cheema Brar
- Division of Pediatric Endocrinology and Diabetes, Department of Pediatrics, New York University Grossman School of Medicine, New York, New York, USA
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Wilson DP. Improving Cholesterol Screening in Children-Is Educating Primary Care Providers Enough? J Pediatr 2022; 249:92-96. [PMID: 35709956 DOI: 10.1016/j.jpeds.2022.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 05/25/2021] [Accepted: 06/08/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Don P Wilson
- Department of Pediatric Endocrinology and Diabetes, Cook Children's Medical Center, Fort Worth, TX.
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Izar MCDO, Giraldez VZR, Bertolami A, Santos Filho RDD, Lottenberg AM, Assad MHV, Saraiva JFK, Chacra APM, Martinez TLR, Bahia LR, Fonseca FAH, Faludi AA, Sposito AC, Chagas ACP, Jannes CE, Amaral CK, Araújo DBD, Cintra DE, Coutinho EDR, Cesena F, Xavier HT, Mota ICP, Giuliano IDCB, Faria Neto JR, Kato JT, Bertolami MC, Miname MH, Castelo MHCG, Lavrador MSF, Machado RM, Souza PGD, Alves RJ, Machado VA, Salgado Filho W. Update of the Brazilian Guideline for Familial Hypercholesterolemia - 2021. Arq Bras Cardiol 2021; 117:782-844. [PMID: 34709306 PMCID: PMC8528358 DOI: 10.36660/abc.20210788] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Affiliation(s)
| | - Viviane Zorzanelli Rocha Giraldez
- Instituto do Coração (InCor) da Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP - Brasil
- Grupo Fleury, São Paulo, SP - Brasil
| | | | | | - Ana Maria Lottenberg
- Hospital Israelita Albert Einstein (HIAE) - Faculdade Israelita de Ciências da Saúde Albert Einstein (FICSAE), São Paulo, SP - Brasil
- Faculdade de Medicina da Universidade de São Paulo, Laboratório de Lípides (LIM10), São Paulo, São Paulo, SP - Brasil
| | | | | | - Ana Paula M Chacra
- Instituto do Coração (InCor) da Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP - Brasil
| | | | | | | | | | - Andrei C Sposito
- Universidade Estadual de Campinas (UNICAMP), Campinas, SP - Brasil
| | | | - Cinthia Elim Jannes
- Instituto do Coração (InCor) da Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP - Brasil
| | | | | | | | | | - Fernando Cesena
- Hospital Israelita Albert Einstein (HIAE), São Paulo, SP - Brasil
| | | | | | | | | | | | | | - Marcio Hiroshi Miname
- Instituto do Coração (InCor) da Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP - Brasil
| | - Maria Helane Costa Gurgel Castelo
- Universidade Federal do Ceará (UFC), Fortaleza, CE - Brasil
- Hospital do Coração de Messejana, Fortaleza, CE - Brasil
- Professora da Faculdade Unichristus, Fortaleza, CE - Brasil
| | - Maria Sílvia Ferrari Lavrador
- Hospital Israelita Albert Einstein (HIAE) - Faculdade Israelita de Ciências da Saúde Albert Einstein (FICSAE), São Paulo, SP - Brasil
| | - Roberta Marcondes Machado
- Faculdade de Medicina da Universidade de São Paulo, Laboratório de Lípides (LIM10), São Paulo, São Paulo, SP - Brasil
| | - Patrícia Guedes de Souza
- Hospital Universitário Professor Edgard Santos da Universidade Federal da Bahia (UFBA), Salvador, BA - Brasil
| | | | | | - Wilson Salgado Filho
- Instituto do Coração (InCor) da Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP - Brasil
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A reassessment of the Japanese clinical diagnostic criteria of familial hypercholesterolemia in a hospital-based cohort using comprehensive genetic analysis. Pract Lab Med 2020; 22:e00180. [PMID: 33134466 PMCID: PMC7585136 DOI: 10.1016/j.plabm.2020.e00180] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 10/15/2020] [Indexed: 11/24/2022] Open
Abstract
Background Clinical diagnostic criteria of familial hypercholesterolemia (FH) in Japan include LDL cholesterol ≥ 180 mg/dL, Achilles tendon thickness ≥ 9.0 mm, and family history. However, few data exist regarding its validation. Design and Methods A series of 680 participants, with a mean LDL cholesterol of 175 mg/dL were enrolled at Kanazawa University Hospital between 2006 and 2018. All had full assessments of, LDL cholesterol, Achilles tendon X-rays, family history records, and genetic analysis of FH-associated genes (LDLR, APOB, and PCSK9). The area under the curve (AUC) of receiver operating characteristic (ROC) curve analysis predicting the presence of FH mutations by each clinical marker were assessed. Results The optimal cutoff values predicting the presence of an FH-associated mutation were 181 mg/dL for LDL cholesterol and ≥7.0 mm for Achilles tendon thickness. AUCs predicting FH mutations were 0.827 for Achilles tendon thickness ≥9.0 mm, 0.889 for LDL cholesterol ≥180 mg/dL, and 0.906 for family history. If Achilles tendon thickness ≥7.0 mm was used as a clinical criterion, then 41 participants (6%) were newly diagnosed with FH and 86 (12%) were newly misclassified as FH. Conclusions Current clinical diagnostic criteria of FH were validated in this cohort. We recommend considering a tentative diagnosis of “potential FH” if the Achilles tendon thickness is ≥ 7.0 mm and <9.0 mm rather than dismissing a diagnosis of FH. Clinical diagnostic criteria of FH in Japan were well validated. The best cutoff value of ATT for predicting FH mutation was 7.0 mm. Threshold of ATT ≥7.0 mm increased the sensitivity to diagnose FH.
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Kohn B, Wilson DP. Universal cholesterol screening of youth-Are pediatric lipidologists smarter than a fifth grader? J Clin Lipidol 2020; 14:747-750. [PMID: 33039346 DOI: 10.1016/j.jacl.2020.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 09/21/2020] [Accepted: 09/21/2020] [Indexed: 11/17/2022]
Affiliation(s)
- Brenda Kohn
- Division Pediatric Endocrinology and Diabetes, NYU Grossman School of Medicine, New York, NY, USA
| | - Don P Wilson
- Cook Children's Medical Center, Fort Worth, TX, USA.
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Anagnostis P, Vaitsi K, Kleitsioti P, Mantsiou C, Pavlogiannis K, Athyros VG, Mikhailidis DP, Goulis DG. Efficacy and safety of statin use in children and adolescents with familial hypercholesterolaemia: a systematic review and meta-analysis of randomized-controlled trials. Endocrine 2020; 69:249-261. [PMID: 32333266 DOI: 10.1007/s12020-020-02302-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Accepted: 04/01/2020] [Indexed: 12/25/2022]
Abstract
PURPOSE Statins are the mainstay of treatment for patients with familial hypercholesterolaemia (FH). However, their efficacy and safety in children and adolescents with FH has not been well-documented. The purpose of this study was to systematically investigate and meta-analyze the best available evidence from randomized-controlled trials (RCTs) regarding the efficacy and safety of statins in this population. METHODS A comprehensive search was conducted in PubMed, Scopus and Cochrane, up to 10 January 2020. Data were expressed as mean differences with 95% confidence intervals (CI). The I2 index was employed for heterogeneity. RESULTS Ten RCTs were included in the qualitative and quantitative analysis (1191 patients, aged 13.3 ± 2.5 years). Compared with placebo, statins led to a mean relative reduction in total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), triglyceride and apolipoprotein B (apo-B) concentrations by -25.5% (95% CI -30.4%, -20.5%; I2 91%), -33.8% (95% CI -40.1%, -27.4%; I2 90%), -8.4% (95% CI -14.8%, -2.03%; I2 26%) and -28.8% (95% CI -33.9%, -23.6%; I2 83%), respectively. High-density lipoprotein cholesterol (HDL-C) was increased by 3.1% (95% CI 1.1%-5.2%; I2 0%). Statins were well-tolerated, with no significant differences in transaminase and creatine kinase levels or other adverse effects compared with placebo. Statins exerted no effect on growth or sexual development. CONCLUSION Statins are quite effective in reducing TC, LDL-C, TG and apo-B and increasing HDL-C concentrations in children and adolescents with FH. No safety issues were seen with statin use.
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Affiliation(s)
- Panagiotis Anagnostis
- Unit of Reproductive Endocrinology, First Department of Obstetrics and Gynecology, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece.
| | - Konstantina Vaitsi
- Unit of Reproductive Endocrinology, First Department of Obstetrics and Gynecology, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Panagiota Kleitsioti
- Unit of Reproductive Endocrinology, First Department of Obstetrics and Gynecology, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Chrysanthi Mantsiou
- Unit of Reproductive Endocrinology, First Department of Obstetrics and Gynecology, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Konstantinos Pavlogiannis
- Unit of Reproductive Endocrinology, First Department of Obstetrics and Gynecology, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Vasilios G Athyros
- 2nd Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, Hippocration Hospital, Thessaloniki, Greece
| | - Dimitri P Mikhailidis
- Department of Clinical Biochemistry, Royal Free Hospital Campus, University College London Medical School, University College London (UCL), London, UK
| | - Dimitrios G Goulis
- Unit of Reproductive Endocrinology, First Department of Obstetrics and Gynecology, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Vuorio A, Kuoppala J, Kovanen PT, Humphries SE, Tonstad S, Wiegman A, Drogari E, Ramaswami U. Statins for children with familial hypercholesterolemia. Cochrane Database Syst Rev 2019; 2019:CD006401. [PMID: 31696945 PMCID: PMC6836374 DOI: 10.1002/14651858.cd006401.pub5] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Familial hypercholesterolemia is one of the most common inherited metabolic diseases and is an autosomal dominant disorder meaning heterozygotes, or carriers, are affected. Those who are homozygous have severe disease. The average worldwide prevalence of heterozygous familial hypercholesterolemia is at least 1 in 500, although recent genetic epidemiological data from Denmark and next generation sequencing data suggest the frequency may be closer to 1 in 250. Diagnosis of familial hypercholesterolemia in children is based on elevated total cholesterol and low-density lipoprotein cholesterol levels or DNA-based analysis, or both. Coronary atherosclerosis has been detected in men with heterozygous familial hypercholesterolemia as young as 17 years old and in women with heterozygous familial hypercholesterolemia at 25 years old. Since the clinical complications of atherosclerosis occur prematurely, especially in men, lifelong treatment, started in childhood, is needed to reduce the risk of cardiovascular disease. In children with the disease, diet was the cornerstone of treatment but the addition of lipid-lowering medications has resulted in a significant improvement in treatment. Anion exchange resins, such as cholestyramine and colestipol, were found to be effective, but they are poorly tolerated. Since the 1990s studies carried out on children aged 6 to 17 years with heterozygous familial hypercholesterolemia have demonstrated significant reductions in their serum total and low-density lipoprotein cholesterol levels. While statins seem to be safe and well-tolerated in children, their long-term safety in this age group is not firmly established. This is an update of a previously published version of this Cochane Review. OBJECTIVES To assess the effectiveness and safety of statins in children with heterozygous familial hypercholesterolemia. SEARCH METHODS Relevant studies were identified from the Group's Inborn Errors and Metabolism Trials Register and Medline. Date of most recent search: 04 November 2019. SELECTION CRITERIA Randomized and controlled clinical studies including participants up to 18 years old, comparing a statin to placebo or to diet alone. DATA COLLECTION AND ANALYSIS Two authors independently assessed studies for inclusion and extracted data. MAIN RESULTS We found 26 potentially eligible studies, of which we included nine randomized placebo-controlled studies (1177 participants). In general, the intervention and follow-up time was short (median 24 weeks; range from six weeks to two years). Statins reduced the mean low-density lipoprotein cholesterol concentration at all time points (high-quality evidence). There may be little or no difference in liver function (serum aspartate and alanine aminotransferase, as well as creatinine kinase concentrations) between treated and placebo groups at any time point (low-quality evidence). There may be little or no difference in myopathy (as measured in change in creatinine levels) (low-quality evidence) or clinical adverse events (moderate-quality evidence) with statins compared to placebo. One study on simvastatin showed that this may slightly improve flow-mediated dilatation of the brachial artery (low-quality evidence), and on pravastatin for two years may have induced a regression in carotid intima media thickness (low-quality evidence). No studies reported rhabdomyolysis (degeneration of skeletal muscle tissue) or death due to rhabdomyolysis, quality of life or compliance to study medication. AUTHORS' CONCLUSIONS Statin treatment is an effective lipid-lowering therapy in children with familial hypercholesterolemia. Few or no safety issues were identified. Statin treatment seems to be safe in the short term, but long-term safety remains unknown. Children treated with statins should be carefully monitored and followed up by their pediatricians and their care transferred to an adult lipidologist once they reach 18 years of age. Large long-term randomized controlled trials are needed to establish the long-term safety issues of statins.
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Affiliation(s)
- Alpo Vuorio
- University of HelsinkiDepartment of Forensic MedicineHelsinkiFinland
| | | | - Petri T Kovanen
- Wihuri Research InstituteKalliolinnatie 4HelsinkiFinlandFIN‐00140
| | - Steve E Humphries
- BHF Laboratories, Royal Free and University College Medical SchoolCenter for Cardiovascular GeneticsThe Rayne Institute5 University StreetLondonUKWC1E 6JJ
| | - Serena Tonstad
- Ullevål University HospitalDept. of Preventive CardiologyOlsoNorway
| | - Albert Wiegman
- Academic Medical CenterDepartment of PediatricsMeibergdreef 9AmsterdamNetherlands1105 AZ
| | - Euridiki Drogari
- National and Kapodistrian University of Athens, Medical SchoolUnit of Metabolic Disorders, First Department of PediatricsAthensGreece
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Mamann N, Lemale J, Karsenty A, Dubern B, Girardet JP, Tounian P. Intermediate-Term Efficacy and Tolerance of Statins in Children. J Pediatr 2019; 210:161-165. [PMID: 31053349 DOI: 10.1016/j.jpeds.2019.03.032] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 03/18/2019] [Accepted: 03/20/2019] [Indexed: 01/20/2023]
Abstract
OBJECTIVES To evaluate the intermediate-term efficacy and tolerance of statins in children and adolescents with familial hypercholesterolemia. STUDY DESIGN A total of 131 children or adolescents treated with statins for familial hypercholesterolemia were prospectively included. The efficacy of treatment was established by the percentage of children who achieved low density lipoprotein-cholesterol (LDL-C) levels <160 mg/dL during treatment. Treatment tolerance was evaluated by the occurrence of clinical or laboratory side effects, regularity of increases in height and weight, and pubertal development. RESULTS The median duration of treatment with statins was 4 years. A median decrease of 32% in LDL-C levels was observed (P < .0001). The therapeutic target (LDL-C <160 mg/dL) was achieved in 67% of cases. Increases in height and weight and sexual maturation were not affected by the treatment. Minor side effects were reported for 24 (18.4%) patients including 3 cases of a clinically asymptomatic increase in creatine phosphokinase (CPK) levels, 2 cases of an increase in CPK levels with muscular symptoms, 14 cases of myalgia without an increase in CPK levels, 3 cases of abdominal pain, 1 case of dysuria, and 1 case of diffuse pain. None of these side effects led to the discontinuation of statin therapy, although a change of statin was required in 7 cases. This new statin was tolerated in all cases. No patients had abnormal liver function during treatment. CONCLUSIONS The results of this large cohort confirm the intermediate-term safety and efficacy of statin therapy in children with familial hypercholesterolemia.
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Affiliation(s)
- Nathalie Mamann
- Pediatric Nutrition and Gastroenterology Department, Trousseau Hospital, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Paris, France.
| | - Julie Lemale
- Pediatric Nutrition and Gastroenterology Department, Trousseau Hospital, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Paris, France
| | - Alexandra Karsenty
- Pediatric Nutrition and Gastroenterology Department, Trousseau Hospital, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Paris, France
| | - Béatrice Dubern
- Pediatric Nutrition and Gastroenterology Department, Trousseau Hospital, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Paris, France
| | - Jean-Philippe Girardet
- Pediatric Nutrition and Gastroenterology Department, Trousseau Hospital, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Paris, France
| | - Patrick Tounian
- Pediatric Nutrition and Gastroenterology Department, Trousseau Hospital, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Paris, France
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Alonso R, Cuevas A, Cafferata A. Diagnosis and Management of Statin Intolerance. J Atheroscler Thromb 2019; 26:207-215. [PMID: 30662020 PMCID: PMC6402887 DOI: 10.5551/jat.rv17030] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Accepted: 12/03/2018] [Indexed: 12/13/2022] Open
Abstract
Statins are the main treatment for hypercholesterolemia and the cornerstone of atherosclerotic cardiovascular disease prevention. Many patients taking statins report muscle-related symptoms, one of the most important causes of statin treatment discontinuation, which is associated with an increased risk of cardiovascular events. Therefore, it is important to identify patients who are truly statin intolerant to avoid unnecessary discontinuation of this beneficial treatment. Some studies indicate that not all muscle complaints are caused by statins, and most patients can tolerate a statin upon re-challenge, down-titration of dose, or switching to another statin. In this paper, we review the definitions of statin intolerance and approaches to reducing cardiovascular risk among individuals reporting statin-associated muscle symptoms.
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Affiliation(s)
- Rodrigo Alonso
- Department of Nutrition, Clinica Las Condes, Santiago de Chile, Chile
| | - Ada Cuevas
- Department of Nutrition, Clinica Las Condes, Santiago de Chile, Chile
| | - Alberto Cafferata
- Cardiovacular Prevention Department. Sanatorio Finochietto, Buenos Aires, Argentina
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Abstract
Purpose of Review To create awareness for the devastating influence of high cholesterol in familial hypercholesterolaemia (FH) on vessel walls. Persons with high LDL-C and a known mutation associated with FH have a 22-fold increase in CVD compared with those with a normal LDL-C and no genetic mutation. If the awareness of the need to diagnose and treat this genetic disorder at an early stage increases, great atherosclerotic impact later in life could be avoided. Every minute a child with heterozygous FH is born somewhere in the world and every day a child with homozygous FH is born. Recent Findings Recent findings include effective therapy on statins from the age of 6 years, with already normalization of the intima-media thickness within 2 years. Newer types of drugs, with the same safety profile and perhaps even more effective, will become available in childhood in the near future. Open for discussion will be whom to treat and with what type of treatment. Next generation sequencing will perhaps easily select those in need of treatment and those at risk of adverse effects. Summary At the end of this review, statements and recommendations for children and adolescents with heterozygous FH are listed.
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Affiliation(s)
- Albert Wiegman
- Department of Pediatrics, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
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Familial hypercholesterolemia supravalvular aortic stenosis and extensive atherosclerosis. Indian Heart J 2018; 70:575-577. [PMID: 30170656 PMCID: PMC6116717 DOI: 10.1016/j.ihj.2018.01.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Revised: 11/01/2017] [Accepted: 01/08/2018] [Indexed: 11/23/2022] Open
Abstract
Familial hypercholesterolemia is an autosomally dominant disorder caused by various mutations in low-density lipoprotein receptor genes. This can lead to premature coronary atherosclerosis and cardiac-related death. The symptoms are more severe in the homozygous type of the disease. Premature malignant atherogenesis leading to aortic root abnormalities causing supravalvular aortic stenosis is rare. Our case demonstrates the diagnostic imaging findings of the phenotype of patients who have severe elevated LDL with familial hypercolesterolemia.
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Vuorio A, Kuoppala J, Kovanen PT, Humphries SE, Tonstad S, Wiegman A, Drogari E, Ramaswami U. Statins for children with familial hypercholesterolemia. Cochrane Database Syst Rev 2017; 7:CD006401. [PMID: 28685504 PMCID: PMC6483457 DOI: 10.1002/14651858.cd006401.pub4] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Familial hypercholesterolemia is one of the most common inherited metabolic diseases and is an autosomal dominant disorder meaning heterozygotes, or carriers, are affected. Those who are homozygous have severe disease. The average worldwide prevalence of heterozygous familial hypercholesterolemia is at least 1 in 500, although recent genetic epidemiological data from Denmark and next generation sequencing data suggest the frequency may be closer to 1 in 250. Diagnosis of familial hypercholesterolemia in children is based on elevated total cholesterol and low-density lipoprotein cholesterol levels or DNA-based analysis, or both. Coronary atherosclerosis has been detected in men with heterozygous familial hypercholesterolemia as young as 17 years old and in women with heterozygous familial hypercholesterolemia at 25 years old. Since the clinical complications of atherosclerosis occur prematurely, especially in men, lifelong treatment, started in childhood, is needed to reduce the risk of cardiovascular disease. In children with the disease, diet was the cornerstone of treatment but the addition of lipid-lowering medications has resulted in a significant improvement in treatment. Anion exchange resins, such as cholestyramine and colestipol, were found to be effective, but they are poorly tolerated. Since the 1990s studies carried out on children aged 6 to 17 years with heterozygous familial hypercholesterolemia have demonstrated significant reductions in their serum total and low-density lipoprotein cholesterol levels. While statins seem to be safe and well-tolerated in children, their long-term safety in this age group is not firmly established. This is an update of a previously published version of this Cochane Review. OBJECTIVES To assess the effectiveness and safety of statins in children with heterozygous familial hypercholesterolemia. SEARCH METHODS Relevant studies were identified from the Group's Inborn Errors and Metabolism Trials Register and Medline.Date of most recent search: 20 February 2017. SELECTION CRITERIA Randomized and controlled clinical studies including participants up to 18 years old, comparing a statin to placebo or to diet alone. DATA COLLECTION AND ANALYSIS Two authors independently assessed studies for inclusion and extracted data. MAIN RESULTS We found 26 potentially eligible studies, of which we included nine randomized placebo-controlled studies (1177 participants). In general, the intervention and follow-up time was short (median 24 weeks; range from six weeks to two years). Statins reduced the mean low-density lipoprotein cholesterol concentration at all time points (moderate quality evidence). Serum aspartate and alanine aminotransferase, as well as creatinine kinase concentrations, did not differ between treated and placebo groups at any time point (low quality evidence). The risks of myopathy (low quality evidence) and clinical adverse events (moderate quality evidence) were very low and also similar in both groups. In one study simvastatin was shown to improve flow-mediated dilatation of the brachial artery (low quality evidence), and in another study treatment with pravastatin for two years induced a significant regression in carotid intima media thickness (low quality evidence). AUTHORS' CONCLUSIONS Statin treatment is an effective lipid-lowering therapy in children with familial hypercholesterolemia. No significant safety issues were identified. Statin treatment seems to be safe in the short term, but long-term safety remains unknown. Children treated with statins should be carefully monitored and followed up by their pediatricians and their care transferred to an adult lipidologist once they reach 18 years of age. Large long-term randomized controlled trials are needed to establish the long-term safety issues of statins.
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Affiliation(s)
- Alpo Vuorio
- Vantaa and Finnish Institute of Occupational HealthMehiläinen Airport Health CentreLappeenrantaFinland
| | | | - Petri T Kovanen
- Wihuri Research InstituteKalliolinnatie 4HelsinkiFinlandFIN‐00140
| | - Steve E Humphries
- BHF Laboratories, Royal Free and University College Medical SchoolCenter for Cardiovascular GeneticsThe Rayne Institute5 University StreetLondonUKWC1E 6JJ
| | - Serena Tonstad
- Ullevål University HospitalDept. of Preventive CardiologyOlsoNorway
| | - Albert Wiegman
- Academic Medical CenterDepartment of PediatricsMeibergdreef 9AmsterdamNetherlands1105 AZ
| | - Euridiki Drogari
- National and Kapodistrian University of Athens, Medical SchoolUnit of Metabolic Disorders, First Department of PediatricsAthensGreece
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Stone NJ, Turin A, Spitz JA, Valle CW, Kazmi S. Statin therapy across the lifespan: evidence in major age groups. Expert Rev Cardiovasc Ther 2016; 14:341-66. [PMID: 26641725 DOI: 10.1586/14779072.2016.1128825] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
This review provides needed perspective on statin efficacy and safety in individuals under 40, 40-75, and > 75 years of age. Starting with the 2013 ACC-AHA cholesterol guidelines extensive evidence base on randomized controlled trials (RCTs) we added references in the past 5 years that discussed statin efficacy and safety over the life span. In those under 40, statins are primarily used for treatment of severe hypercholesterolemia, often familial, and they are well tolerated. In middle-aged adults, statins have strong evidence for benefit in primary and secondary prevention trials; however, in primary prevention, a clinician-patient risk discussion should precede statin prescription in order to determine appropriate treatment. In those over 75, issues of statin intensity and net benefit loom large as associated comorbidity, polypharmacy, and potential for adverse effects impact the decision to use statins with RCT data strongest in support of use in secondary prevention. Statin drugs have been studied by RCTs in a large number of individuals. In those groups shown to benefit, statins have reduced the risk of atherosclerotic cardiovascular disease with few side effects as compared to controls. This review has detailed considerations that should occur when statins are given to individuals in different age groups.
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Affiliation(s)
- Neil J Stone
- a Department of Medicine (Cardiology) , Northwestern University , Chicago , IL , USA
| | - Alexander Turin
- b Department of Medicine , Loyola University Medical Center , Maywood , IL , USA
| | - Jared A Spitz
- c Feinberg School of Medicine , Northwestern University , Chicago , IL , USA
| | - Christopher W Valle
- c Feinberg School of Medicine , Northwestern University , Chicago , IL , USA
| | - Sakina Kazmi
- d Department of Medicine (Cardiology), Clinical Research Associate , Northwestern University , Chicago , IL , USA
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The non-immunosuppressive management of childhood nephrotic syndrome. Pediatr Nephrol 2016; 31:1383-402. [PMID: 26556028 PMCID: PMC4943972 DOI: 10.1007/s00467-015-3241-0] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Revised: 09/21/2015] [Accepted: 09/30/2015] [Indexed: 12/20/2022]
Abstract
Idiopathic nephrotic syndrome (INS) is one of the most common renal diseases found in the paediatric population and is associated with significant complications, including infection and thrombosis. A high proportion of children enter sustained remission before adulthood, and therapy must therefore mitigate the childhood complications, while minimising the long-term risk to health. Here we address the main complications of INS and summarise the available evidence and guidance to aid the clinician in determining the appropriate treatment for children with INS under their care. Additionally, we highlight areas where no consensus regarding appropriate management has been reached. In this review, we detail the reasons why routine prophylactic antimicrobial and antithrombotic therapy are not warranted in INS and emphasise the conservative management of oedema. When pharmacological intervention is required for the treatment of oedema, we provide guidance to aid the clinician in determining the appropriate therapy. Additionally, we discuss obesity and growth, fracture risk, dyslipidaemia and thyroid dysfunction associated with INS. Where appropriate, we describe how recent developments in research have identified potential novel therapeutic targets.
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Abstract
Cardiovascular disease (CVD) is still the most prominent cause of death and morbidity in the world, and one of the major risk factors for developing CVD is hypercholesterolemia. Familial hypercholesterolemia (FH) is a dominantly inherited disorder characterized by markedly elevated plasma low-density lipoprotein cholesterol and premature coronary heart disease. Currently, several treatment options are available for children with FH. Lifestyle adjustments are the first step in treatment. If this is not sufficient, statins are the preferred initial pharmacological therapy and they have been proven effective and safe. However, treatment goals are often not achieved and, hence, there is a need for novel treatment options. Currently, several options are being studied in adults and first results are promising. However, studies in children are still to be awaited.
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Affiliation(s)
- Ilse K Luirink
- Department of Pediatrics, Emma Children's Hospital, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands,
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18
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Canadian Cardiovascular Society Position Statement on Familial Hypercholesterolemia. Can J Cardiol 2014; 30:1471-81. [DOI: 10.1016/j.cjca.2014.09.028] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2014] [Revised: 09/22/2014] [Accepted: 09/22/2014] [Indexed: 01/13/2023] Open
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Vuorio A, Kuoppala J, Kovanen PT, Humphries SE, Tonstad S, Wiegman A, Drogari E. Statins for children with familial hypercholesterolemia. Cochrane Database Syst Rev 2014:CD006401. [PMID: 25054950 DOI: 10.1002/14651858.cd006401.pub3] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND Familial hypercholesterolemia is one of the most common inherited metabolic diseases; the average worldwide prevalence of heterozygous familial hypercholesterolemia is at least 1 in 500. Diagnosis of familial hypercholesterolemia in children is based on highly elevated low-density lipoprotein (LDL) cholesterol level or DNA-based analysis, or both. Coronary atherosclerosis has been detected in men with heterozygous familial hypercholesterolemia as young as 17 years old and in women with heterozygous familial hypercholesterolemia at 25 years old. Since the clinical complications of atherosclerosis occur prematurely, especially in men, lifelong hypolipidemic measures, started in childhood, are needed to reduce the risk of cardiovascular disease. In children with familial hypercholesterolemia, diet is as yet the cornerstone of treatment. Anion exchange resins, such as cholestyramine and colestipol, have also been found to be effective, but are poorly tolerated. Since the 1990s statin studies have been carried out among children with familial hypercholesterolemia (aged 7 to 17 years). Statins greatly reduced their serum LDL cholesterol levels. Even though statins seem to be safe and well-tolerated in children, their long-term safety in this age group is not firmly established. OBJECTIVES To assess the effectiveness and safety of statins in children with familial hypercholesterolemia. SEARCH METHODS Relevant studies were identified from the Group's Inborn Errors and Metabolism Trials Register and Medline.Date of most recent search: 14 October 2013. SELECTION CRITERIA Randomized and controlled clinical studies including participants up to 18 years old, comparing a statin to placebo or to diet alone. DATA COLLECTION AND ANALYSIS Two authors independently assessed studies for inclusion and extracted data. MAIN RESULTS We found 21 potentially eligible studies, of which we included eight randomized placebo-controlled studies (1074 participants). In general, the intervention and follow-up time was short (median 24 weeks; range from six weeks to two years). Statins reduced the mean LDL cholesterol concentration at all time points. Serum aspartate and alanine aminotransferase, as well as creatinine kinase concentrations, did not differ between treated and placebo groups at any time point. The risks of myopathy and clinical adverse events were very low and also similar in both groups. In one study simvastatin was shown to improve flow-mediated dilatation of the brachial artery, and in another study treatment with pravastatin for two years induced a significant regression in carotid intima media thickness. AUTHORS' CONCLUSIONS Statin treatment is an efficient lipid-lowering therapy in children with familial hypercholesterolemia. No significant safety issues were identified. Statin treatment seems to be safe in the short term, but long-term safety is unknown. Children treated with statins should be carefully monitored and followed up by their pediatricians or physicians into adulthood. Large long-term randomized controlled trials are needed to establish the long-term safety issues of statins.
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Affiliation(s)
- Alpo Vuorio
- Mehiläinen Airport Health Centre, Vantaa and Finnish Institute of Occupational Health, Lappeenranta, Finland
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21
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Abstract
Familial hypercholesterolemia (FH) is a genetic disorder of lipoprotein metabolism resulting in elevated serum low-density lipoprotein (LDL) cholesterol levels leading to increased risk for premature cardiovascular diseases (CVDs). The diagnosis of this condition is based on clinical features, family history, and elevated LDL-cholesterol levels aided more recently by genetic testing. As the atherosclerotic burden is dependent on the degree and duration of exposure to raised LDL-cholesterol levels, early diagnosis and initiation of treatment is paramount. Statins are presently the mainstay in the management of these patients, although newer drugs, LDL apheresis, and other investigational therapies may play a role in certain subsets of FH, which are challenging to treat. Together these novel treatments have notably improved the prognosis of FH, especially that of the heterozygous patients. Despite these achievements, a majority of children fail to attain targeted lipid goals owing to persistent shortcomings in diagnosis, monitoring, and treatment. This review aims to highlight the screening, diagnosis, goals of therapy, and management options in patients with FH.
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Affiliation(s)
- Mithun J Varghese
- Department of Cardiology, Christian Medical College, Vellore, Tamil Nadu, India
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22
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Abstract
BACKGROUND This study evaluated the effectiveness of long-term intensive lipid-lowering therapy in children and adolescents with familial hypercholesterolaemia. METHODS The charts of 89 children and adolescents with heterozygous familial hypercholesterolaemia among ∼1000 patients treated from 1974 to 2008 were reviewed. Familial hypercholesterolaemia was defined as low-density lipoprotein cholesterol level >90th percentile in individuals with a history of familial hypercholesterolaemia. RESULTS Of the 89 patients, 51% were male; the mean age at diagnosis was 8 ± 4 years, and the mean follow-up was 13 ± 8 years. Baseline and most recent low-density lipoprotein cholesterol levels (mg/dl) under treatment were 250 ± 50 and 142 ± 49, respectively, reduced 43% from baseline (p < 0.0001). At the most recent visit, 39 patients received statin monotherapy, mainly atorvastatin or rosuvastatin, and 50 (56%) patients received combination therapy, mainly vytorin or rosuvastain/ezetimibe, 15 patients were >30 years of age, and none developed symptomatic cardiovascular disease or needed revascularisation. CONCLUSIONS Long-term statin-based therapy can reduce low-density lipoprotein cholesterol levels in most children and adolescents with heterozygous familial hypercholesterolaemia and decrease cardiovascular risk significantly.
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Myśliwiec M, Walczak M, Małecka-Tendera E, Dobrzańska A, Cybulska B, Filipiak K, Mazur A, Jarosz-Chobot P, Szadkowska A, Rynkiewicz A, Chybicka A, Socha P, Brandt A, Bautembach-Minkowska J, Zdrojewski T, Limon J, Gidding SS, Banach M. Management of familial hypercholesterolemia in children and adolescents. Position paper of the Polish Lipid Expert Forum. J Clin Lipidol 2014; 8:173-80. [DOI: 10.1016/j.jacl.2014.01.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2013] [Revised: 01/03/2014] [Accepted: 01/04/2014] [Indexed: 10/25/2022]
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France M, Schofield J, Kwok S, Soran H. Treatment of homozygous familial hypercholesterolemia. ACTA ACUST UNITED AC 2014. [DOI: 10.2217/clp.13.79] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Cao S, Zhou Y, Xu P, Wang Y, Yan J, Bin W, Qiu F, Kang N. Berberine metabolites exhibit triglyceride-lowering effects via activation of AMP-activated protein kinase in Hep G2 cells. JOURNAL OF ETHNOPHARMACOLOGY 2013; 149:576-582. [PMID: 23899453 DOI: 10.1016/j.jep.2013.07.025] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/30/2013] [Revised: 06/22/2013] [Accepted: 07/23/2013] [Indexed: 06/02/2023]
Abstract
ETHNOPHARMACOLOGICAL RELEVANCE Rhizoma coptidis (Huanglian in Chinese) is commonly used in Chinese folk medicine to treat diarrhea, diabetes, hypertension, hyperlipidemia and tumors. This herb has increasingly gained attention because of its use as a hypolipidemic herb. Berberine (BBR) is the most important constituent of R. coptidis that contribute to the pharmacological efficacy of the herb. AIM OF THE STUDY Pharmacokinetic studies have indicated that BBR has poor oral bioavailability. Interestingly, several reports show that absorbed BBR is extensively metabolized in rats and humans. We speculate that the BBR metabolites might be responsible for the pharmacological effects. The aim of this study is to examine BBR metabolites for their triglyceride (TG)-lowering activities and the molecular mechanism to clarify BBR genuine effective forms in vivo. MATERIALS AND METHODS Four BBR metabolites were examined their TG-lowering effects with a commercial triglyceride assay kit. Real-time PCR and Western blotting were used to confirm genes and proteins of interest, respectively. RESULTS Among those BBR metabolites, M2 exhibited the more potential effects on TG-lowering and AMP-activated protein kinase (AMPK) activation in Hep G2 cells as compared with BBR. Moreover, BBR and M2 inhibited gene expressions of acetyl-CoA carboxylase (ACC), fatty acid synthase (FAS), glycerol-3-phosphate acyltransferase (GPAT) and 3-hydroxy-3-methylglutaryl coenzyme A reductase (HMGR), but motivated gene expression of medium chain acyl-CoA dehydrogenase (mCAD) significantly. CONCLUSIONS The results suggested that the TG-lowering effects of BBR and M2 might be partially mediated by the up-regulation of lipolysis gene expressions and down-regulation of lipogenesis gene expressions through activation of the AMPK signaling pathway. BBR and its metabolites might be in vivo active forms of oral doses of BBR, and M2 might be a promising drug candidate against hyperlipidemia.
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Affiliation(s)
- Shijie Cao
- Department of Biochemistry and Molecular Biology, Shenyang Pharmaceutical University, Shenyang 110016, PR China
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Lamaida N, Capuano E, Pinto L, Capuano E, Capuano R, Capuano V. The safety of statins in children. Acta Paediatr 2013; 102:857-62. [PMID: 23631461 DOI: 10.1111/apa.12280] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2012] [Accepted: 04/26/2013] [Indexed: 11/28/2022]
Abstract
UNLABELLED Current American Academy of Pediatrics Guidelines recommended that statins should be considered as a first-line agent in children as early as 8 years of age. The aim of our work is to assess the safety of 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors in children with hypercholesterolaemia. CONCLUSION Controlled studies in children show that statin monotherapy is efficacious, well tolerated and safe in the short-time. Unfortunately, these studies have relatively short-term follow-up periods, and therefore, long-term safety remains unclear.
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Affiliation(s)
- Norman Lamaida
- Department of Cardiology; Mercato san Severino Hospital; Salerno Italy
| | - Ernesto Capuano
- Department of Cardiology; Mercato san Severino Hospital; Salerno Italy
| | - Laura Pinto
- Department of Cardiology; Mercato san Severino Hospital; Salerno Italy
| | - Eduardo Capuano
- Department of Cardiology; Mercato san Severino Hospital; Salerno Italy
| | - Rocco Capuano
- Department of Cardiology; Mercato san Severino Hospital; Salerno Italy
| | - Vincenzo Capuano
- Department of Cardiology; Mercato san Severino Hospital; Salerno Italy
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Nordestgaard BG, Chapman MJ, Humphries SE, Ginsberg HN, Masana L, Descamps OS, Wiklund O, Hegele RA, Raal FJ, Defesche JC, Wiegman A, Santos RD, Watts GF, Parhofer KG, Hovingh GK, Kovanen PT, Boileau C, Averna M, Borén J, Bruckert E, Catapano AL, Kuivenhoven JA, Pajukanta P, Ray K, Stalenhoef AFH, Stroes E, Taskinen MR, Tybjærg-Hansen A. Familial hypercholesterolaemia is underdiagnosed and undertreated in the general population: guidance for clinicians to prevent coronary heart disease: consensus statement of the European Atherosclerosis Society. Eur Heart J 2013. [PMID: 23956253 DOI: 10.1093/eurheartj.eht273] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
AIMS The first aim was to critically evaluate the extent to which familial hypercholesterolaemia (FH) is underdiagnosed and undertreated. The second aim was to provide guidance for screening and treatment of FH, in order to prevent coronary heart disease (CHD). METHODS AND RESULTS Of the theoretical estimated prevalence of 1/500 for heterozygous FH, <1% are diagnosed in most countries. Recently, direct screening in a Northern European general population diagnosed approximately 1/200 with heterozygous FH. All reported studies document failure to achieve recommended LDL cholesterol targets in a large proportion of individuals with FH, and up to 13-fold increased risk of CHD. Based on prevalences between 1/500 and 1/200, between 14 and 34 million individuals worldwide have FH. We recommend that children, adults, and families should be screened for FH if a person or family member presents with FH, a plasma cholesterol level in an adult ≥8 mmol/L(≥310 mg/dL) or a child ≥6 mmol/L(≥230 mg/dL), premature CHD, tendon xanthomas, or sudden premature cardiac death. In FH, low-density lipoprotein cholesterol targets are <3.5 mmol/L(<135 mg/dL) for children, <2.5 mmol/L(<100 mg/dL) for adults, and <1.8 mmol/L(<70 mg/dL) for adults with known CHD or diabetes. In addition to lifestyle and dietary counselling, treatment priorities are (i) in children, statins, ezetimibe, and bile acid binding resins, and (ii) in adults, maximal potent statin dose, ezetimibe, and bile acid binding resins. Lipoprotein apheresis can be offered in homozygotes and in treatment-resistant heterozygotes with CHD. CONCLUSION Owing to severe underdiagnosis and undertreatment of FH, there is an urgent worldwide need for diagnostic screening together with early and aggressive treatment of this extremely high-risk condition.
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Affiliation(s)
- Børge G Nordestgaard
- Department of Clinical Biochemistry, Herlev Hospital, Copenhagen University Hospital, University of Copenhagen, DK-2730 Herlev, Copenhagen, Denmark
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28
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Nordestgaard BG, Chapman MJ, Humphries SE, Ginsberg HN, Masana L, Descamps OS, Wiklund O, Hegele RA, Raal FJ, Defesche JC, Wiegman A, Santos RD, Watts GF, Parhofer KG, Hovingh GK, Kovanen PT, Boileau C, Averna M, Borén J, Bruckert E, Catapano AL, Kuivenhoven JA, Pajukanta P, Ray K, Stalenhoef AFH, Stroes E, Taskinen MR, Tybjærg-Hansen A. Familial hypercholesterolaemia is underdiagnosed and undertreated in the general population: guidance for clinicians to prevent coronary heart disease: consensus statement of the European Atherosclerosis Society. Eur Heart J 2013; 34:3478-90a. [PMID: 23956253 PMCID: PMC3844152 DOI: 10.1093/eurheartj/eht273] [Citation(s) in RCA: 1859] [Impact Index Per Article: 169.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Aims The first aim was to critically evaluate the extent to which familial hypercholesterolaemia (FH) is underdiagnosed and undertreated. The second aim was to provide guidance for screening and treatment of FH, in order to prevent coronary heart disease (CHD). Methods and results Of the theoretical estimated prevalence of 1/500 for heterozygous FH, <1% are diagnosed in most countries. Recently, direct screening in a Northern European general population diagnosed approximately 1/200 with heterozygous FH. All reported studies document failure to achieve recommended LDL cholesterol targets in a large proportion of individuals with FH, and up to 13-fold increased risk of CHD. Based on prevalences between 1/500 and 1/200, between 14 and 34 million individuals worldwide have FH. We recommend that children, adults, and families should be screened for FH if a person or family member presents with FH, a plasma cholesterol level in an adult ≥8 mmol/L(≥310 mg/dL) or a child ≥6 mmol/L(≥230 mg/dL), premature CHD, tendon xanthomas, or sudden premature cardiac death. In FH, low-density lipoprotein cholesterol targets are <3.5 mmol/L(<135 mg/dL) for children, <2.5 mmol/L(<100 mg/dL) for adults, and <1.8 mmol/L(<70 mg/dL) for adults with known CHD or diabetes. In addition to lifestyle and dietary counselling, treatment priorities are (i) in children, statins, ezetimibe, and bile acid binding resins, and (ii) in adults, maximal potent statin dose, ezetimibe, and bile acid binding resins. Lipoprotein apheresis can be offered in homozygotes and in treatment-resistant heterozygotes with CHD. Conclusion Owing to severe underdiagnosis and undertreatment of FH, there is an urgent worldwide need for diagnostic screening together with early and aggressive treatment of this extremely high-risk condition.
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Affiliation(s)
- Børge G Nordestgaard
- Department of Clinical Biochemistry, Herlev Hospital, Copenhagen University Hospital, University of Copenhagen, DK-2730 Herlev, Copenhagen, Denmark
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Martin AC, Coakley J, Forbes DA, Sullivan DR, Watts GF. Familial hypercholesterolaemia in children and adolescents: a new paediatric model of care. J Paediatr Child Health 2013; 49:E263-72. [PMID: 23252991 DOI: 10.1111/jpc.12036] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/26/2012] [Indexed: 01/31/2023]
Abstract
Familial hypercholesterolaemia (FH) is a common genetic disorder affecting more than 8000 children and adolescents throughout Australia. It results in marked elevation in plasma low-density lipoprotein cholesterol levels from birth that predisposes individuals to premature coronary heart disease in adult life. The majority of children and adolescents with FH are undiagnosed, as symptoms and signs only develop after decades of hypercholesterolaemia. Cascade screening of family members after detecting FH in an index case is an effective approach that allows the diagnosis of FH to be made in the young, before significant atherosclerosis develops. With the availability of effective therapies, mainly statins, paediatricians are ideally placed to improve the outcomes of this disorder by detecting and managing hypercholesterolaemia in childhood, thereby preventing premature coronary artery disease. We describe a new paediatric model of care for FH.
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Affiliation(s)
- Andrew C Martin
- Department of Paediatric and Adolescent Medicine, Princess Margaret Hospital for Children, Perth,Western Australia, Australia.
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Watts GF, Juniper A, van Bockxmeer F, Ademi Z, Liew D, OʼLeary P. Familial hypercholesterolaemia: a review with emphasis on evidence for treatment, new models of care and health economic evaluations. INT J EVID-BASED HEA 2012; 10:211-21. [DOI: 10.1111/j.1744-1609.2012.00272.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Marcovecchio ML, Dunger DB. Evaluating cardio-renal protection for adolescents with type 1 diabetes: the current AdDIT trial. PRACTICAL DIABETES 2012. [DOI: 10.1002/pdi.1684] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Miscellaneous non-inflammatory musculoskeletal conditions. Rare thesaurismosis and xanthomatosis. Best Pract Res Clin Rheumatol 2012; 25:683-701. [PMID: 22142747 DOI: 10.1016/j.berh.2011.10.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2011] [Accepted: 10/13/2011] [Indexed: 11/21/2022]
Abstract
The focus will be on xanthomatosis, a tissue danger signal which needs to be recognized by the clinician, and its relationship with monogenetic lipoprotein disorders (cholesterol, triglycerides), bile acid and sterol metabolism, particularly on metabolic pathways and genetics as well as on musculoskeletal and cardiovascular involvement, and their implications for clinical management. The critical question is to assess coronary heart disease risk, requiring correct identification of the pattern of lipoprotein disorders and of the causes (primary or secondary). Familial hypercholesterolemia must be suspected in adults and children with raised total cholesterol, especially when there is a personal or a family history of premature coronary heart disease, usually requiring potent statins to achieve adequate LDL-cholesterol lowering, even if we do not know safety of long-term therapy and whether treatments of dyslipidemia early in life prevent cardiovascular diseases in adulthood. Cerebrotendinous xanthomatosis is a treatable disease and must be suspected if there is a history of infantile chronic diarrhea and/or juvenile cataracts, even in the absence of tendon xanthomas. Current evidence for the prevention and screening, diagnosis, and treatment of dyslipidemia are available for the clinicians.
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Braamskamp MJ, Wijburg FA, Wiegman A. Drug Therapy of Hypercholesterolaemia in Children and Adolescents. Drugs 2012; 72:759-72. [DOI: 10.2165/11632810-000000000-00000] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Abstract
Familial hypercholesterolaemia is a disorder of low-density lipoprotein (LDL) cholesterol metabolism, which is associated with the onset of vascular changes associated with coronary heart disease in childhood. This disorder has co-dominant transmission with a prevalence of one in 500 in the general population. Cascade screening is the most effective method of identifying children. Children in the at-risk group should have their cholesterol levels checked between the age of 2 and 10 years. Children with LDL cholesterol levels ≥ 3.4 mmol/L are likely to suffer from this disorder, although at this level there is a significant false positive rate. Molecular genetic testing is available for the LDL receptor gene, APOB gene and the PCSK9 gene. This is the most specific test for familial hypercholesterolaemia but has a false negative rate of 20-50%. Once diagnosed, treatment should be considered in children with an LDL cholesterol level ≥ 4.9 mmol/L. If the child has two other risk factors or a positive family history, this threshold should be lowered to ≥4.1 mmol/L. Guidelines recommend that treatment should be commenced by the age of 10 years, although some advise waiting until menarche in females. Statin therapy is currently recommended as first line treatment. Randomised placebo trials have shown that statin therapy reduces LDL cholesterol levels by 25% and is not associated with increased risk of adverse events. These are short-term studies, and longer follow-up will be required to definitively prove efficacy and safety.
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Affiliation(s)
- Robert N Justo
- Paediatric Cardiology, Queensland Paediatric Cardiac Service, Mater Children's Hospital, Brisbane, Queensland, Australia.
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Acosta MT, Kardel PG, Walsh KS, Rosenbaum KN, Gioia GA, Packer RJ. Lovastatin as treatment for neurocognitive deficits in neurofibromatosis type 1: phase I study. Pediatr Neurol 2011; 45:241-5. [PMID: 21907886 DOI: 10.1016/j.pediatrneurol.2011.06.016] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2011] [Accepted: 06/30/2011] [Indexed: 10/17/2022]
Abstract
In a neurofibromatosis type 1 murine model, treatment with lovastatin reversed cognitive disabilities. We report on a phase I study examining the safety and tolerability of lovastatin in children with neurofibromatosis type 1. Twenty-four children with neurofibromatosis type 1 underwent a dose-escalation protocol for 3 months to identify the maximum tolerated dose and potential toxicity. Minimal side effects were evident, and no child experienced dose-limiting toxicity. Cognitive evaluations were completed before and after treatment, and the results suggested improvement in areas of verbal and nonverbal memory. Additional analyses, using reliable change indices, indicated improvements exceeding those of test-retest or practice effects in some participants. These observations may be analogous to the improvements observed in a neurofibromatosis type 1 murine model treated with lovastatin, although further study and replication are required. The safety and preliminary cognitive results support the need for a larger phase II trial in this population.
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Affiliation(s)
- Maria T Acosta
- Department of Neurology, Jennifer and Daniel Gilbert Neurofibromatosis Institute, Children's National Medical Center, Washington, D.C. 20010, USA.
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Carreau V, Girardet JP, Bruckert E. Long-term follow-up of statin treatment in a cohort of children with familial hypercholesterolemia: efficacy and tolerability. Paediatr Drugs 2011; 13:267-75. [PMID: 21692550 DOI: 10.2165/11591650-000000000-00000] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
BACKGROUND Early identification of children with familial hypercholesterolemia (FH) makes it possible to start lipid-lowering therapy at a young age in order to prevent cardiovascular disease. Numerous randomized, often placebo-controlled, studies have assessed the efficacy and safety of statins in children with FH. OBJECTIVE The aim of this pragmatic observational study was to evaluate pravastatin treatment efficacy and tolerability for a long period of time, and to assess how these results translate in 'real-life' clinical practice. METHODS We analyzed all medical files of young hypercholesterolemic patients referred to two specialized French centers. This population of 185 pravastatin-treated children with FH, with a mean baseline cholesterol level above 300 mg/dL, in most of whom genetic diagnosis was achieved, was followed-up for a mean duration of 2 years 2 months. The mean age for starting pravastatin was 11 years; in one of five children, treatment was started before the age of 8 years, mostly because of severe hypercholesterolemia or a family history of coronary heart disease. RESULTS A 16.9-19.2% decrease in total cholesterol level (21-24% for low-density lipoprotein cholesterol) was observed. Growth and puberty were not affected by statin treatment. A review of the medical files showed that 13% of children had side effects, most of which were minor; four of these children had muscular symptoms possibly related to the treatment. This frequency is lower than that observed in adults, and comparable to other studies in children. CONCLUSIONS In this large cohort of FH children, the efficacy and tolerability of pravastatin therapy in real-life conditions was demonstrated to be similar to that in randomized controlled studies.
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Affiliation(s)
- Valerie Carreau
- University Hospital Pitié Salpêtrière, 47-83 Boulevard de L'Hôpital, Paris, France.
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Descamps OS, Tenoutasse S, Stephenne X, Gies I, Beauloye V, Lebrethon MC, De Beaufort C, De Waele K, Scheen A, Rietzschel E, Mangano A, Panier JP, Ducobu J, Langlois M, Balligand JL, Legat P, Blaton V, Muls E, Van Gaal L, Sokal E, Rooman R, Carpentier Y, De Backer G, Heller FR. Management of familial hypercholesterolemia in children and young adults: consensus paper developed by a panel of lipidologists, cardiologists, paediatricians, nutritionists, gastroenterologists, general practitioners and a patient organization. Atherosclerosis 2011; 218:272-80. [PMID: 21762914 DOI: 10.1016/j.atherosclerosis.2011.06.016] [Citation(s) in RCA: 99] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2010] [Revised: 06/08/2011] [Accepted: 06/09/2011] [Indexed: 01/06/2023]
Abstract
UNLABELLED Since heterozygous familial hypercholesterolemia (HeFH) is a disease that exposes the individual from birth onwards to severe hypercholesterolemia with the development of early cardiovascular disease, a clear consensus on the management of this disease in young patients is necessary. In Belgium, a panel of paediatricians, specialists in (adult) lipid management, general practitioners and representatives of the FH patient organization agreed on the following common recommendations. 1. Screening for HeFH should be performed only in children older than 2 years when HeFH has been identified or is suspected (based on a genetic test or clinical criteria) in one parent.2. The diagnostic procedure includes, as a first step, the establishment of a clear diagnosis of HeFH in one of the parents. If this precondition is satisfied, a low-density-lipoprotein cholesterol (LDL-C) levelabove 3.5 mmol/L (135 mg/dL) in the suspected child is predictive for differentiating affected from non-affected children. 3. A low saturated fat and low cholesterol diet should be started after 2 years, under the supervision of a dietician or nutritionist.4. The pharmacological treatment, using statins as first line drugs, should usually be started after 10 years if LDL-C levels remain above 5 mmol/L (190 mg/dL), or above 4 mmol/L (160 mg/dL) in the presence of a causative mutation, a family history of early cardiovascular disease or severe risk factors. The objective is to reduce LDL-C by at least 30% between 10 and 14 years and, thereafter, to reach LDL-C levels of less than 3.4 mmol/L (130 mg/dL). CONCLUSION The aim of this consensus statement is to achieve more consistent management in the identification and treatment of children with HeFH in Belgium.
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Affiliation(s)
- O S Descamps
- Département de Médecine Interne et Centre de Recherche Médicale de Jolimont, Hôpital de Jolimont, Haine Saint-Paul, Belgium
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Glaser NS, Geller DH, Haqq A, Gitelman S, Malloy M. Detecting and treating hyperlipidemia in children with type 1 diabetes mellitus: are standard guidelines applicable to this special population? Pediatr Diabetes 2011; 12:442-59. [PMID: 21054719 DOI: 10.1111/j.1399-5448.2010.00709.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Affiliation(s)
- Nicole S Glaser
- Department of Pediatrics, University of California at Davis, CA 95817, USA.
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Cascade Screening for Familial Hypercholesterolemia (FH). PLOS CURRENTS 2011; 3:RRN1238. [PMID: 21633520 PMCID: PMC3102597 DOI: 10.1371/currents.rrn1238] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Accepted: 05/26/2011] [Indexed: 11/28/2022]
Abstract
Familial hypercholesterolemia (FH) is an autosomal dominant disorder characterized by abnormally high concentrations of low-density lipoprotein (LDL) cholesterol in the blood, which predisposes affected persons to premature coronary heart disease (CHD) and death. FH is one of the most common inherited disorders and the most common one known to cause premature CHD in people of European descent. The vast majority of people with FH have inherited a single mutation from one parent in either the LDL receptor (LDLR), apolipoprotein B (APOB), or proprotein convertase subtilisin/kexin type 9 (PCSK9) genes. Despite their greatly elevated risk of coronary heart disease, most individuals with FH remain undiagnosed, untreated, or inadequately treated. Cascade screening is a mechanism for identifying people at risk for a genetic condition by a process of systematic family tracing. The National Institute for Health and Clinical Excellence in the United Kingdom recommends cascade screening of close biological relatives of people with a clinical diagnosis of FH in order to effectively identify additional FH patients. The ultimate goal of this testing is to reduce morbidity and mortality from heart disease in persons with FH through early diagnosis and effective disease management. The goal of this article is to outline the available evidence on the clinical validity and utility of cascade screening for FH, while emphasizing the availability, usefulness, and recommendation for including DNA testing (if the disease-causing mutation has been identified).
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Nouvelles recommandations pour la prise en charge des hypercholestérolémies de l’enfant. Arch Pediatr 2011. [DOI: 10.1016/s0929-693x(11)71002-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Girardet JP, Luc G, Rieu D, Bruckert E, Darmaun D, Farnier M. Prise en charge des hypercholestérolémies de l’enfant : recommandations du Comité de nutrition de la Société française de pédiatrie et de la Nouvelle société française d’athérosclérose. Arch Pediatr 2011; 18:217-29. [DOI: 10.1016/j.arcped.2010.10.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2010] [Accepted: 10/20/2010] [Indexed: 01/06/2023]
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Masoura C, Pitsavos C, Aznaouridis K, Skoumas I, Vlachopoulos C, Stefanadis C. Arterial endothelial function and wall thickness in familial hypercholesterolemia and familial combined hyperlipidemia and the effect of statins. A systematic review and meta-analysis. Atherosclerosis 2011; 214:129-38. [DOI: 10.1016/j.atherosclerosis.2010.10.008] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2010] [Revised: 09/23/2010] [Accepted: 10/08/2010] [Indexed: 11/17/2022]
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O'Gorman CSM, O'Neill MB, Conwell LS. Considering statins for cholesterol-reduction in children if lifestyle and diet changes do not improve their health: a review of the risks and benefits. Vasc Health Risk Manag 2010; 7:1-14. [PMID: 21339908 PMCID: PMC3037084 DOI: 10.2147/vhrm.s7356] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Children who appear healthy, even if they have one or more recognized cardiovascular risk factors, do not generally have outcomes of cardiovascular or other vascular disease during childhood. Historically, pediatric medicine has not aggressively screened for or treated cardiovascular risk factors in otherwise healthy children. However, studies such as the P-Day Study (Pathobiological Determinants of Atherosclerosis in Youth), and the Bogalusa Heart Study, indicate that healthy children at remarkably young ages can have evidence of significant atherosclerosis. With the increasing prevalence of pediatric obesity, can we expect more health problems related to the consequences of pediatric dyslipidemia, hypertriglyceridemia, and atherosclerosis in the future? For many years, medications have been available and used in adult populations to treat dyslipidemia. In recent years, reports of short-term safety of some of these medications in children have been published. However, none of these studies have detailed long-term follow-up, and therefore none have described potential late side-effects of early cholesterol-lowering therapy, or potential benefits in terms of reduction of or delay in cardiovascular or other vascular end-points. In 2007, the American Heart Association published a scientific statement on the use of cholesterol-lowering therapy in pediatric patients. In this review paper, we discuss some of the current literature on cholesterol-lowering therapy in children, including the statins that are currently available for use in children, and some of the cautions with using these and other cholesterol-lowering medications. A central tenet of this review is that medications are not a substitute for dietary and lifestyle interventions, and that even in children on cholesterol-lowering medications, physicians should take every opportunity to encourage children and their parents to make healthy diet and lifestyle choices.
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Affiliation(s)
- Clodagh S M O'Gorman
- Graduate Entry Medical School, University of Limerick, Ireland, and Mid-Western Regional Hospital, Limerick, Ireland.
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Nemati MH, Astaneh B. Optimal management of familial hypercholesterolemia: treatment and management strategies. Vasc Health Risk Manag 2010; 6:1079-88. [PMID: 21191428 PMCID: PMC3004511 DOI: 10.2147/vhrm.s8283] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2010] [Indexed: 01/17/2023] Open
Abstract
Familial hypercholesterolemia is an autosomally dominant disorder caused by various mutations in low-density lipoprotein receptor genes. This will lead to elevated levels of total and low-density lipoprotein cholesterol, which may in turn lead to premature coronary atherosclerosis and cardiac-related death. The symptoms are more severe in the homozygous type of the disease. Different options for the treatment of affected patients are now available. Diet therapy, pharmacologic therapy, lipid apheresis, and liver transplantation are among the various treatments. We clinically review the treatment and management strategies for the disease in order to shed light on the optimal management of familial hypercholesterolemia.
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Halpern A, Mancini MC, Magalhães MEC, Fisberg M, Radominski R, Bertolami MC, Bertolami A, de Melo ME, Zanella MT, Queiroz MS, Nery M. Metabolic syndrome, dyslipidemia, hypertension and type 2 diabetes in youth: from diagnosis to treatment. Diabetol Metab Syndr 2010; 2:55. [PMID: 20718958 PMCID: PMC2939537 DOI: 10.1186/1758-5996-2-55] [Citation(s) in RCA: 87] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2009] [Accepted: 08/18/2010] [Indexed: 02/06/2023] Open
Abstract
Overweight and obesity in youth is a worldwide public health problem. Overweight and obesity in childhood and adolescents have a substantial effect upon many systems, resulting in clinical conditions such as metabolic syndrome, early atherosclerosis, dyslipidemia, hypertension and type 2 diabetes (T2D). Obesity and the type of body fat distribution are still the core aspects of insulin resistance and seem to be the physiopathologic links common to metabolic syndrome, cardiovascular disease and T2D. The earlier the appearance of the clustering of risk factors and the higher the time of exposure, the greater will be the chance of developing coronary disease with a more severe endpoint. The age when the event may occur seems to be related to the presence and aggregation of risk factors throughout life.The treatment in this age-group is non pharmacological and aims at promoting changes in lifestyle. However, pharmacological treatments are indicated in special situations.The major goals in dietary treatments are not only limited to weight loss, but also to an improvement in the quality of life. Modification of risk factors associated to comorbidities, personal satisfaction of the child or adolescent and trying to establish healthy life habits from an early age are also important. There is a continuous debate on the best possible exercise to do, for children or adolescents, in order to lose weight. The prescription of physical activity to children and adolescents requires extensive integrated work among multidisciplinary teams, patients and their families, in order to reach therapeutic success.The most important conclusion drawn from this symposium was that if the growing prevalence of overweight and obesity continues at this pace, the result will be a population of children and adolescents with metabolic syndrome. This would lead to high mortality rates in young adults, changing the current increasing trend of worldwide longevity. Government actions and a better understanding of the causes of this problem must be implemented worldwide, by aiming at the prevention of obesity in children and adolescents.
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Affiliation(s)
- Alfredo Halpern
- Group of Obesity and Metabolic Syndrome, Endocrinology and Metabolism Service, Hospital das Clínicas da Faculdade de Medicina, São Paulo University (HC-FMUSP). Av. Dr. Enéas de Carvalho Aguiar, 155 - 8º andar - bloco 3. São Paulo, Brazil
| | - Marcio C Mancini
- Group of Obesity and Metabolic Syndrome, Endocrinology and Metabolism Service, Hospital das Clínicas da Faculdade de Medicina, São Paulo University (HC-FMUSP). Av. Dr. Enéas de Carvalho Aguiar, 155 - 8º andar - bloco 3. São Paulo, Brazil
| | - Maria Eliane C Magalhães
- Arterial Hypertension and Lipids Sector of Hospital Universitário Pedro Ernesto - State University of Rio de Janeiro (UERJ). Rua São Francisco Xavier, 524. Rio de Janeiro, Brazil
| | - Mauro Fisberg
- Adolescent Center, Department of Pediatrics, Federal University of Sao Paulo (UNIFESP). Rua Pedro de Toledo, 650, 2o andar. São Paulo, Brazil
| | - Rosana Radominski
- Endocrinology and Metabolism Service of Hospital de Clínicas, Department of Nutrition, Federal University of Paraná (UFPR). Rua General Carneiro, 181. Curitiba, Brazil
| | - Marcelo C Bertolami
- Dante Pazzanese Institute of Cardiology of the São Paulo State Health Department. Av. Dr. Dante Pazzanese, 500. São Paulo, Brazil
| | - Adriana Bertolami
- Group of Diabetes, Endocrinology and Metabolism Service, Hospital das Clínicas da Faculdade de Medicina, São Paulo University (HC-FMUSP). Av. Dr. Enéas de Carvalho Aguiar, 155 - 8º andar - bloco 3. São Paulo, Brazil
| | - Maria Edna de Melo
- Group of Obesity and Metabolic Syndrome, Endocrinology and Metabolism Service, Hospital das Clínicas da Faculdade de Medicina, São Paulo University (HC-FMUSP). Av. Dr. Enéas de Carvalho Aguiar, 155 - 8º andar - bloco 3. São Paulo, Brazil
| | - Maria Teresa Zanella
- Service of Endocrinology, Department of Medicine, Federal University of São Paulo (UNIFESP). Rua Pedro de Toledo, 650, 2º andar. São Paulo, Brazil
| | - Marcia S Queiroz
- Group of Diabetes, Endocrinology and Metabolism Service, Hospital das Clínicas da Faculdade de Medicina, São Paulo University (HC-FMUSP). Av. Dr. Enéas de Carvalho Aguiar, 155 - 8º andar - bloco 3. São Paulo, Brazil
| | - Marcia Nery
- Group of Diabetes, Endocrinology and Metabolism Service, Hospital das Clínicas da Faculdade de Medicina, São Paulo University (HC-FMUSP). Av. Dr. Enéas de Carvalho Aguiar, 155 - 8º andar - bloco 3. São Paulo, Brazil
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Abstract
PURPOSE OF REVIEW To review the recent findings on evaluation and management of dyslipidemia in childhood and adolescence, giving a critical view on new therapeutic approaches. RECENT FINDINGS In 2008, the American Academy of Pediatrics released an updated policy statement recommending more frequent screening to detect dyslipidemia in childhood and the first-line use of statins in children with dyslipidemia who did not respond to lifestyle intervention and who were more than 8 years of age. These recommendations have caused a lot of controversy within the medical community and media. This debate is also sharpened by the fact that only few trials have investigated the long-term efficacy of statins on prevention of adult cardiovascular disease, their application in dyslipidemias other than familial hypercholesterolemia and the use of new pharmacological tools. SUMMARY The purpose of our paper could not be achieved clearly without a review of the physiology of cholesterol metabolism together with an analysis of causes of primary and secondary dyslipidemia affecting children. Moreover, recent knowledge on lipid-lowering therapy is reviewed.
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Gooding HC, de Ferranti SD. Cardiovascular risk assessment and cholesterol management in adolescents: getting to the heart of the matter. Curr Opin Pediatr 2010; 22:398-404. [PMID: 20489635 PMCID: PMC2951679 DOI: 10.1097/mop.0b013e32833a6e22] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Adolescence is a common time for the identification of cardiovascular disease risk factors, including elevated cholesterol. Guidelines for the detection and treatment of hypercholesterolemia differ for children and adults. This review highlights these differences and discusses special considerations for cholesterol management in the adolescent population. RECENT FINDINGS Several longitudinal studies have confirmed that the number of cardiovascular risk factors present in adolescence, including elevated cholesterol, lead to atherosclerosis in adults. There is increased awareness that other chronic medical conditions, including diabetes, congenital heart disease, inflammatory diseases, and childhood cancer, can accelerate this process. There is a move to screen and treat more young patients with elevated cholesterol to prevent future cardiovascular disease. New markers of atherosclerosis are being used to quantify cardiovascular disease risk in adolescents in research populations. The safety and efficacy of several interventions, including drug therapy, is increasingly established. SUMMARY Comprehensive cardiovascular risk assessment is important for adolescent health and includes assessment of family history and tobacco use along with measurement of body mass index and blood pressure. Additionally, cholesterol screening is recommended for overweight adolescents or those with an unknown family history and for all patients by the age of 20. Providers caring for adolescents should be familiar with both the pediatric and adult cholesterol screening and treatment guidelines as well as how common adolescent conditions affect cholesterol levels.
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Affiliation(s)
- Holly C Gooding
- Division of Adolescent/Young Adult Medicine, Department of Medicine, Children's Hospital Boston, Harvard Medical School, Boston, Massachusetts 02115, USA.
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Vuorio A, Kuoppala J, Kovanen PT, Humphries SE, Strandberg T, Tonstad S, Gylling H. Statins for children with familial hypercholesterolemia. Cochrane Database Syst Rev 2010:CD006401. [PMID: 20614444 DOI: 10.1002/14651858.cd006401.pub2] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Familial hypercholesterolemia is one of the most common inherited metabolic diseases; the average worldwide prevalence of heterozygous familial hypercholesterolemia is about 1 in 500. Diagnosis of familial hypercholesterolemia in children is based on two measurements of low-density lipoprotein cholesterol level above 4.0 mmol/L or a DNA-based analysis. Coronary stenosis has been detected in men with familial hypercholesterolemia as young as 17 years old and in women with familial hypercholesterolemia at 25 years old. Atherosclerosis and its clinical complications occur prematurely, especially in men, thus lifelong hypolipidemic measures, started in childhood, are needed to reduce the risk of cardiovascular diseases. In children with familial hypercholesterolemia children, so far diet has been the main mode of treatment. Anion exchange resins, such as cholestyramine and colestipol, have also been found to be effective but are generally considered unpalatable and therefore poorly tolerated. Since the 1990s statin trials have been carried out among children with familial hypercholesterolemia (aged 7 to 17 years), and statins reduced their serum low-density lipoprotein cholesterol levels by 23% to 40%. The safety of statins among children is not well known even though statins seem to be safe and well-tolerated in adults. OBJECTIVES To assess the effectiveness and safety of statins in children with familial hypercholesterolemia. SEARCH STRATEGY Relevant trials were identified from the Group's Inborn Errors and Metabolism Trials Register and Medline.Date of most recent search: 11 March 2010. SELECTION CRITERIA Randomized and controlled clinical trials including participants up to 18 years old comparing a statin to placebo or to diet alone. DATA COLLECTION AND ANALYSIS Two authors independently assessed studies for inclusion and extracted data. MAIN RESULTS We found 19 potentially eligible studies of which we included eight randomized placebo-controlled trials (897 participants). Statins reduced the mean low-density lipoprotein cholesterol concentration at all time points. There was no difference between serum aspartate and alanine aminotransferase as well as creatine kinase concentrations at any time-point. The risks of myopathy and clinical adverse events were also similar in both groups. In one study simvastatin was shown to improve flow-mediated dilation of the brachial artery. AUTHORS' CONCLUSIONS Statin treatment is an efficient lipid-lowering therapy in children with familial hypercholesterolemia. It seems to be safe in the short term but long-term safety is unknown. Children treated with statins should be carefully followed up by their pediatricians. Large long-term randomized controlled trials are needed to establish the long-term safety of statins.
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Affiliation(s)
- Alpo Vuorio
- Mehilainen Airport Medical Center, Vantaa, Finland
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50
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Hopkins PN. Encouraging appropriate treatment for familial hypercholesterolemia. ACTA ACUST UNITED AC 2010. [DOI: 10.2217/clp.10.22] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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