Patterns of Lipid Lowering Therapy among Children Ages 8-20 Years

Universal lipid screening in adolescents to identify familial hypercholesterolemia in a large healthcare system

BACKGROUND

Familial hypercholesterolemia (FH) is an inherited condition that likely affects 1 in 300 people often requiring pharmacologic intervention in childhood.

OBJECTIVES

We hypothesized that current strategies for pediatric lipid screening fail to detect and treat most FH, but data analysis may suggest specific methods to improve outcomes.

METHODS

We retrospectively searched 392,129 patient records of 11-17-year-olds in Kaiser Permanente Southern California for data related to recommended universal pediatric lipid screening. We categorized subjects as Probable or Possible FH and evaluated FH pharmacotherapy status.

RESULTS

37% of the population received lipid screening with 0.13% (1 in 769) having Probable or Possible FH. Results at each step of the process showed progressive decreases in detection and treatment. We characterized 1 in 3448 subjects as Probable FH which is only 8.7% of cases expected from the prevalence of FH in the population. 45% of Probable FH cases received ongoing pharmacotherapy which is 1 in 7688 of the cohort (3.9% of expected cases). One major correctable reason for this drop-off was using obesity to target screening and treatment decisions rather than following the recommended universal screening. We found a strong association of obesity with screening (risk ratio (RR) 2.74 [confidence interval (CI) 2.71-2.76]), but not with FH (RR 0.72, CI 0.47-1.10).

CONCLUSION

This current universal lipid screening strategy, likely typical of US practice, fails to detect and treat the supermajority of FH cases, increasing risk for adult coronary artery disease. To address the specific deficiencies we observed, we suggest improvements to detect and treat FH.

Adherence with lipid screening guidelines in standard- and high-risk children and adolescents

Because atherosclerosis begins in childhood, universal lipid screening is recommended with special attention to conditions predisposing to early atherosclerosis. Data about real-world penetration of these guidelines is not available.

METHODS

Retrospective cohort study using MarketScan® commercial and Medicaid insurance claims databases, a geographically representative sample of U.S. children. Subjects who passed through the 9- to 11-year window and had continuous insurance coverage between 1/1/2013 and 12/31/2016 were studied. Multivariable models were calculated, evaluating the association between other patient factors and the likelihood of screening. The primary hypothesis was that screening rates would be low, but that high-risk conditions would be associated with a higher likelihood of screening.

RESULTS

In total, 572,522 children (51% male, 33% black, 11% Hispanic, 51% Medicaid) were studied. The prevalence of high-risk conditions was 2.2%. In unadjusted and adjusted analyses, these subjects were more likely to be screened than standard-risk subjects (47% vs. 20%, OR: 3.7, 95% CI 3.5-3.8, P < .001). Within this group, the diagnosis-specific likelihood of screening varied (26-69%). Endocrinopathies (OR 5.4, 95% CI 5.2-5.7), solid organ transplants (OR 5.0, 95% CI 3.8-6.6), and metabolic disease (OR 3.9, 95% CI 3.1-5.0, all P < .001) were associated with the highest likelihood of undergoing screening.

CONCLUSIONS

Despite national recommendations, lipid screening was performed in a minority of children. Though subjects with high-risk conditions had a higher likelihood of screening, rates remained low. This study highlights the need for research and advocacy regarding obstacles to lipid screening of children in the United States.

Lipid temporal trends in normal-weight youth

Atherosclerosis begins in youth, partly driven by excess weight (EW) and abnormal lipids. Despite pediatric obesity worsening, lipids improved. Given the relation between EW and abnormal lipids, changes in normal-weight (NW) youth may be relevant. We examined the proportions and temporal trends of youth with abnormal lipids who were NW versus EW.

METHODS

Analysis was done from National Health and Nutrition Examination Surveys 1988-2016. Data were extracted for 10- to 20-year-olds measured with anthropometrics and laboratory testing to determine proportions of NW versus EW with total cholesterol >190 mg/dL, high-density lipoprotein cholesterol (HDL-C) <40 mg/dL, and calculated non-HDL-C >145 mg/dL (N = 14,785). In survey-weighted regression analysis, a weight-status interaction term was used to examine effect modification in the lipid temporal trend.

RESULTS

Over time, EW prevalence increased, whereas dyslipidemia decreased (trend P value < .001 for both). For the pooled sample, EW more than doubled the risk of each lipid disorder (P < .0001 for each). However, for each abnormal lipid, 26%-63% were NW. As the temporal trend in abnormal lipids declined, the proportion with abnormal lipids who were NW also declined. On regression analysis, temporal declines in NW and EW differed for HDL-C.

CONCLUSIONS

NW constituted more than a quarter to half of youth with abnormal lipids. Over time, youth with abnormal lipids were less often NW. The novel observation that a high proportion of youth with abnormal lipids are NW is relevant to debates on universal lipid screening, the focus on weight reduction in youth lipid management, and conventional wisdom in cardiometabolic health.

Effectiveness and Safety of Statin Therapy in Children: A Real-World Clinical Practice Experience

BACKGROUND

Statin use for hypercholesterolemia in children is predominantly reported from short-term clinical trials. In this study, we assess the efficacy and safety of statin treatment in clinical pediatric practice.

METHODS

Records of all patients who began statin treatment at age <18 years and remained on statins for >6 months from 5 pediatric lipid clinics were reviewed. Information at baseline and from all clinic evaluations after statin initiation was recorded, including lipid measurements, statin drug/dose, safety measures (anthropometry, hepatic enzymes, creatine kinase levels), and symptoms. Lipid changes on statin therapy were assessed from baseline to 6 ± 3 months and from 6 ± 3 months to last follow-up with a mixed-effects model, using piecewise linear splines to describe temporal changes, controlling for repeated measures, sex, and age.

RESULTS

There were 289 patients with median low-density lipoprotein cholesterol (LDL-C) of 5.3 mmol/L (interquartile range [IQR]:4.5-6.5) and mean age of 12.4 ± 2.9 years at statin initiation. Median duration of therapy was 2.7 years (IQR: 1.6-4.5) with 95% on statins at last evaluation. There were significant decreases in total cholesterol, LDL-C, and non-high-density lipoprotein cholesterol (non-HDL-C) from baseline to 6 ± 3 months (P < 0.001) and from 6 ±3 months to last follow-up (P < 0.001). Triglycerides and HDL-C were unchanged but the triglyceride to HDL-C ratio decreased significantly by late follow-up. At final evaluation, median LDL-C had decreased to 3.4 mmol/L (IQR:2.8-4.2). No patient had statins discontinued for safety measures or symptoms.

CONCLUSIONS

In real-world clinical practice, intermediate-term statin treatment is effective and safe in children and adolescents with severe LDL-C elevation.

Markers of cholesterol synthesis are elevated in adolescents and young adults with type 2 diabetes

BACKGROUND

Changes in cholesterol absorption and cholesterol synthesis may promote dyslipidemia and cardiovascular disease in individuals with type 2 diabetes mellitus (T2DM).

OBJECTIVE

To assess cholesterol synthesis and absorption in lean individuals, obese individuals, and individuals with T2DM.

METHODS

We measured lathosterol and lanosterol (markers of cholesterol synthesis) as well as campesterol and β-sitosterol (markers of cholesterol absorption) in the serum of 15 to 26 years old individuals with T2DM (n = 95), as well as their lean (n = 98) and obese (n = 92) controls.

RESULTS

Individuals with T2DM showed a 51% increase in lathosterol and a 65% increase in lanosterol compared to lean controls. Similarly, obese individuals showed a 31% increase in lathosterol compared to lean controls. Lathosterol and lanosterol were positively correlated with body mass index, fasting insulin and glucose, serum triglycerides, and C-reactive protein, and negatively correlated with HDL-cholesterol. In contrast, campesterol and β-sitosterol were not altered in individuals with T2DM. Moreover, campesterol and β-sitosterol were negatively correlated with body mass index, fasting insulin, and C-reactive protein and were positively correlated with HDL-cholesterol.

CONCLUSIONS

Adolescents and young adults with T2DM show evidence of increased cholesterol synthesis compared to non-diabetic lean controls. These findings suggest that T2DM may promote cardiovascular disease by increasing cholesterol synthesis, and provide additional rationale for the use of cholesterol synthesis inhibitors in this group.

Safety of Prescribing Statins in Childhood Dyslipidemia

Hyperlipidemia is on the rise in pediatrics, leading to early coronary artery disease complications. Familial hypercholesterolemia is an important risk factor, with the homozygous subtype being more dangerous, yet less prevalent than the heterozygous subtype. Statins are shown to be an effective treatment in this population. This systematic review will emphasize the safety of such drug class in pediatrics, while taking into consideration the latest cholesterol guideline. Cochrane Library, Clinicaltrials.gov, and PubMed were reviewed systematically in June 2019 and rechecked in November 2019 for the past 5 years with keywords like child, safety, hyperlipidemia, and statins, which resulted in nine randomized clinical trials. In short, statins are shown to be intermediately effective—median decrease of low-density lipoprotein cholesterol was 32% achieving the target of < 160 mg/dL in 67% of patients—in lowering lipid levels yet preventing early complications. They are also considered safely tolerated in most cases, even when taken for extended periods, but still not evidently permissible for children below 8 years old, which was the average age of all participants in the trials. Statins should not be given generally for pediatrics of less than 8 years old, in contrast to what was mentioned in the American Heart Association guideline (0–19 age range), since there is no evidence supporting their safety within this age group.

Effect of supplementation with omega-3 fatty acids on hypertriglyceridemia in pediatric patients with obesity

Background The beneficial effects of treating hypertriglyceridemic adults with omega-3 fatty acids have been reported. However, information regarding omega-3 treatment of pediatric patients is limited. To evaluate the efficacy and safety of administering omega-3 fatty acids (3 g/day for 12 weeks) to children/adolescents with obesity and hypertriglyceridemia. Methods A randomized, double-blind, placebo-controlled, parallel study involving pediatric patients (10-16 years old) with obesity and hypertriglyceridemia was conducted. The National Center for Health Statistics (CDC) defines obesity as a body mass index (BMI) ≥95th percentile. Subjects with triglyceride concentrations ranging from 150 to 1000 mg/dL were randomized into two groups: those receiving omega-3 fatty acids (eicosapentaenoic and docosahexaenoic acids) (n = 65) and those receiving a placebo (n = 65) for 12 weeks. Serum triglyceride concentrations were always measured from 8 to 9 am after a 12-h fast. Results By the end of treatment, triglyceride concentrations had decreased by 39.1% in the omega-3 group and 14.6% in the placebo group (p < 0.01). The incidence of adverse gastrointestinal events (e.g. flatulence, belching) was 41.2% and 6.2% in the omega-3 and placebo groups, respectively (p < 0.01). There were no serious drug-related adverse events. Conclusions Supplementation with 3 g/day of omega-3 fatty acids is a safe and effective option for treating hypertriglyceridemia in children and adolescents with obesity.

Management of cardiovascular disease risk in teens with type 1 diabetes: Perspectives of teens with and without dyslipidemia and parents

Hypertension and dyslipidemia are often suboptimally managed in teens with type 1 diabetes (T1D). Teen and parent perspectives on hypertension and dyslipidemia management need further study to enhance the development of cardiovascular disease (CVD) risk factor management plans. We sought to describe barriers to and strategies for CVD risk factor management. Teens with T1D with and without dyslipidemia and parents of teens with T1D with and without dyslipidemia underwent one-on-one semi-structured interviews conducted by trained personnel at a diabetes center; interviews continued until thematic saturation was reached. Teens and parents of teens described their knowledge, attitudes, and beliefs regarding heart health and CVD risk factors (hypertension and dyslipidemia). Researchers undertook a content analysis and categorized central themes as strategies and barriers. In total, 22 teens and 25 parents completed interviews. Teens were 17.4 ± 1.7 years old with T1D duration 9.7 ± 4.0 years; 45% had dyslipidemia. Parents were between 41 and 60 years old, 84% were mothers, and 40% had teens with dyslipidemia. Barriers to heart health included an obesity-promoting environment, parental distrust of medications, and limited teen knowledge about hypertension and dyslipidemia. Strategies included specific and realistic guidance from providers, family support of teen lifestyle management, and having exercise partners. While teen and parent perspectives were often similar, some themes applied only to teens or parents. Central themes provide actionable guidance to enhance hypertension and dyslipidemia management. Providers should consider teen and parent perspectives when managing CVD risk factors to enhance engagement with CVD risk management.

Management of Hypertension and High Low-Density Lipoprotein in Pediatric Type 1 Diabetes

OBJECTIVE

To evaluate hypertension and hyperlipidemia management patterns in youth with type 1 diabetes and to assess perceived effectiveness of management strategies and barriers to management.

STUDY DESIGN

An electronic survey, including clinical scenarios, fielded to pediatric providers (members of the American Diabetes Association Diabetes in Youth Interest Group, Pediatric Endocrine Society, or T1D Exchange).

RESULTS

Respondents (N = 207, 86% MDs, 68% female) were practicing clinicians for youth with type 1 diabetes. As an initial recommendation, the overwhelming majority of respondents (83%-99%) endorsed lifestyle and nonmedical recommendations (eg, improve glycemic control) for hypertension and hyperlipidemia. Yet, few (6%-17%) reported these recommendations as effective. Many respondents (57%) reported referring to another specialist for hypertension, whereas few (8%) reported referring to another specialist for hyperlipidemia management. Approximately one-fifth (21%) of respondents never initiate antihypertensive medications, whereas only 8% never initiate lipid-lowering medication. Among prescribers, the majority of respondents only started antihypertensive or lipid-lowering medications after persistent elevations and in the setting of either ineffective lifestyle or nonmedical interventions or additional cardiovascular risk factors. More than two-thirds of respondents endorsed medications as often effective for hypertension and hyperlipidemia (68% and 69%, respectively).

CONCLUSIONS

Pediatric diabetes providers commonly defer prescribing antihypertensive and lipid-lowering medications until nonmedication interventions have been ineffective. Most providers describe medications, but not lifestyle interventions, as often effective. Efforts to align clinical practice with clinical guidelines are needed.

Statin Use and the Risk of Type 2 Diabetes Mellitus in Children and Adolescents

OBJECTIVE

There is increasing evidence of an association between statin use and type 2 diabetes mellitus (T2DM) in adults, yet this relationship has never been studied in children or adolescents and may have important implications for assessing risks and benefits of treatment in this population. We estimated the association between statin use and the risk of T2DM in children with and without a dyslipidemia diagnosis.

METHODS

Propensity scores were used to match new users of statins with a minimum 50 percent of days covered (PDC) in the first year of use to up to 10 nonusers. Analyses were stratified by a dyslipidemia diagnosis based on recent evidence suggesting a potentially protective effect of familial hypercholesterolemia on T2DM. In sensitivity analyses, we varied this period of exclusion and PDC. Cox proportional hazard models compared the hazard of the outcome between the exposed and unexposed patients.

RESULTS

A total of 21,243,305 patients met the eligibility criteria, 2085 (0.01%) of whom met the exposure definition and 1046 (50%) of whom had a dyslipidemia diagnosis. Statin use was associated with an increased risk of T2DM in children without dyslipidemia (hazard ratio 1.96, 95% confidence interval 1.20-3.22), but not in children with dyslipidemia (hazard ratio 1.11, 95% confidence interval 0.65-1.90). The results were consistent across variations in the exclusion period and PDC.

CONCLUSIONS

Statin use was associated with an increased likelihood of developing T2DM in children without dyslipidemia. Physicians and patients need to weigh the possible risk of T2DM against the long-term benefits of statin therapy at a young age.

Overweight adolescents with type 2 diabetes have significantly higher lipoprotein abnormalities than those with type 1 diabetes

AIM

Diabetes-associated glucoregulatory derangements may precipitate atherogenesis in childhood and CVD risk, particularly with obesity. We aimed to delineate lipoprotein profile differences between children with type 1 and 2 diabetes who are overweight/obese.

METHODS

Data were obtained from electronic medical records of patients ≥85th BMI percentile with type 1 (n=159) and type 2 (n=77) diabetes, ages 12-19y. Group differences were evaluated by correlations and general linear modeling analysis, adjusting for BMI, HbA1c, and diabetes duration.

RESULTS

There were no group differences in TC, LDL, or non-HDL. Fewer subjects with type 1 diabetes had low HDL (17 vs. 30%; P<0.05). While no difference in HbA1c level was observed between groups, HbA1c was positively correlated with TC (P≤0.0001), LDL (P≤0.0001), non-HDL (P≤0.0001), ApoB100 (P≤0.0001), and LDL pattern B (P≤0.0001). In adjusted models, apoB100 (85.4 vs. 91.3mg/dl; P<0.05) and incidence of LDL pattern B (21 vs. 42%; P<0.01) were lower in subjects with type 1 diabetes. BMI was inversely correlated with HDL, HDL-2 and HDL-3 (all P≤0.0001). The correlation of BMI with HDL-2 and HDL-3 were attenuated when evaluating subjects by diabetes type.

CONCLUSIONS

Despite having no difference in absolute LDL levels, children with type 2 diabetes were more likely to have small, dense LDL particle pattern, higher apo B100 and lower total HDL, HDL-2, and HDL-3 fractions. Furthermore, poor glycemic control was associated with abnormal lipoprotein profiles in patients with both type 1 and 2 diabetes.

Patterns and predictors of medication adherence to lipid-lowering therapy in children aged 8 to 20 years

BACKGROUND

The American Academy of Pediatrics recommends lipid-lowering therapy (LLT) for children at high risk of cardiovascular disease. However, the use of LLT in children is rare, and rates of nonadherence are unknown.

OBJECTIVE

To identify patterns of use and predictors of nonadherence to LLT in children aged 8 to 20 years and the subgroup with dyslipidemia.

METHODS

Commercially insured patients with a new dispensing for an LLT were included. Nonadherence was defined as a gap of >90 days between the last dispensing plus the medication days supply and the next dispensing or censoring. Descriptive statistics characterize the patterns of LLT adherence and class-specific drug switching. Kaplan-Meier curves and multivariable Cox proportional hazard models identified time to, and predictors of, nonadherence for the cohort and the dyslipidemia subgroup.

RESULTS

Of the 8710 patients meeting inclusion criteria, 87% were nonadherent. Statins were the most common index prescription, and patients with an index statin dispensing were more likely to have multiple comorbidities and other prescription drug use. In multivariable analyses, nonadherence was inversely associated with dyslipidemia (hazard ratio [HR] = 0.61, 95% confidence interval [CI] = 0.57-0.65), chronic kidney disease (HR = 0.69, 95% CI = 0.54-0.88), higher outpatient (HR = 0.87, 95% CI = 0.77-0.98), and inpatient (HR = 0.83, 95% CI = 0.70-0.97) use. When limited to patients with dyslipidemia, nonadherence was related to age (HR = 1.21, 95% CI = 1.07-1.38) and obesity (HR = 1.23, 95% CI = 1.02-1.49).

CONCLUSIONS

Despite recommendations to begin continuous treatment early for high-risk children, nonadherence to LLT is frequent in this population, with modestly higher adherence in children with dyslipidemia.