The safety of statins in children

Hyperlipidemia in Children and Adolescents

While coronary artery disease (CAD) is thought to be a disease of adulthood, atherosclerosis can originate in childhood and adolescence. There is a paucity of randomized controlled treatment trials regarding dyslipidemia among the younger population. However, it is apparent that childhood dyslipidemia is associated with an earlier onset of CAD. Most recent guidelines by the American College of Cardiology (ACC) and American Heart Association (AHA) focus on lifestyle modification and lifetime risk of atherosclerotic disease, as well as adequate screening measures. Genetic factors, environmental contributors such as pollution, obesity linked to poor nutrition, and sedentary lifestyles are shown to be associated with increased lipid levels and early CAD among children and adolescents. Familial hyperlipidemia is one of the most prevalent genetic diseases and can affect 1 in 250 individuals. A multimodal treatment plan is most effective for children and adolescents with dyslipidemia including lifestyle changes (a modified diet and moderate physical activity) and pharmacologic intervention. The mainstay of pharmacologic treatment for childhood dyslipidemia is similar to that of adults. Statins are the most widely used medications. Newer medications have proven integral in treatment for genetic dyslipidemias including evolocumab and evinacumab.

Guiding future paediatric drug studies based on existing pharmacokinetic and efficacy data: Cardiovascular drugs as a proof of concept

INTRODUCTION

Off-label drug use in the paediatric population is common, and the lack of high-quality efficacy studies poses patients at risk for failing pharmacotherapy. Next to efficacy studies, pharmacokinetic (PK) studies are increasingly used to inform paediatric dose selection. As resources for paediatric trials are limited, we aimed to summarize existing PK and efficacy studies to identify knowledge gaps in available evidence supporting paediatric dosing recommendations, thereby taking paediatric cardiovascular drugs as proof of concept.

METHODS

For each cardiovascular drug, paediatric indication and prespecified age group, together comprising one record, the authorized state was assessed. Next, for off-label records, the highest level of evidence was scored. High-quality efficacy studies were defined as meta-analysis or randomized controlled trials. Other comparative research, noncomparative research or consensus-based expert opinions were considered low quality. The level of evidence for PK studies was scored per drug and per age group, but regardless of indication.

RESULTS

A total of 58 drugs included 417 records, of which 279 (67%) were off-label. Of all off-label records, the majority (81%) were not supported by high-quality efficacy studies, but for 140 of these records (62%) high-quality PK studies were available.

CONCLUSION

We demonstrated that for the majority of off-label cardiovascular drugs, only low-quality efficacy studies were available. However, high-quality PK studies were frequently available. Combining these PK data with extrapolation of efficacy data from adults may help to close the current information gap and prioritize the drugs for which clinical studies and safety data are urgently needed.

PoLA/CFPiP/PCS/PSLD/PSD/PSH guidelines on diagnosis and therapy of lipid disorders in Poland 2021

In Poland there are still nearly 20 million individuals with hypercholesterolaemia, most of them are unaware of their condition; that is also why only ca. 5% of patients with familial hypercholesterolaemia have been diagnosed; that is why other rare cholesterol metabolism disorders are so rarely diagnosed in Poland. Let us hope that these guidelines, being an effect of work of experts representing 6 main scientific societies, as well as the network of PoLA lipid centers being a part of the EAS lipid centers, certification of lipidologists by PoLA, or the growing number of centers for rare diseases, with a network planned by the Ministry of Health, improvements in coordinated care for patients after myocardial infarction (KOS-Zawał), reimbursement of innovative agents, as well as introduction in Poland of an effective primary prevention program, will make improvement in relation to these unmet needs in diagnostics and treatment of lipid disorders possible.

Hyperlipidemia

Cardiovascular disease remains the top cause of morbidity and mortality in the United States. Atherosclerotic plaques are known to start in adolescence, and, therefore, young adults can be affected by coronary artery disease. Children with known risk factors, such as genetic predisposition, including familial hyperlipidemias, diabetes, and renal diseases, are at higher risk. With childhood obesity becoming an epidemic in certain parts of the United States, this problem is further highlighted as an important issue affecting children's health. There are unclear recommendations for pediatricians regarding cholesterol screening of pediatric populations, when to initiate hyperlipidemia treatment with statin therapy, and when to refer to a specialist for further management. This article reviews the epidemiology and pathophysiology of hyperlipidemia, recommendations for screening and types of screening, management (including pharmacology), prognosis, and prevention.

Drug Dose Selection in Pediatric Obesity: Available Information for the Most Commonly Prescribed Drugs to Children

Obesity rates continue to rise in children, and little guidance exists regarding the need for adjustment away from total body weight-based doses for those prescribing drugs to this population of children. A majority of drugs prescribed to children with obesity result in either sub-therapeutic or supra-therapeutic concentrations, placing these children at risk for treatment failure and drug toxicities. In this review, we highlight available obesity-specific pharmacokinetic and dosing information for the most frequently prescribed drugs to children in the inpatient and outpatient clinical settings. We also comment on available dosing recommendations for drugs prescribed to treat common pediatric obesity-related comorbidities. This review highlights that there is no safe or proven 'rule of thumb,' for dosing drugs for children with obesity, and a striking lack of pharmacokinetic data to support the creation of dosing guidelines for children with obesity for the most commonly prescribed drugs. It is important that those prescribing for children with obesity are aware of these gaps in knowledge and of potential drug treatment failure or adverse events related to drug toxicity as a result of these knowledge gaps. Until more data are available, we recommend close monitoring of drug response and adverse events in children with obesity receiving commonly prescribed drugs.

Safety and Efficacy of Atorvastatin in Human Immunodeficiency Virus-infected Children, Adolescents and Young Adults With Hyperlipidemia

BACKGROUND

Human immunodeficiency virus (HIV)-infected children receiving antiretroviral therapy (ART) have increased prevalence of hyperlipidemia and risk factors for cardiovascular disease. No studies have investigated the efficacy and safety of statins in this population.

METHODS

HIV-infected youth 10 to <24 years of age on stable ART with low-density lipoprotein cholesterol (LDL-C) ≥130 mg/dL for ≥6 months initiated atorvastatin 10 mg once daily. Atorvastatin was increased to 20 mg if LDL-C efficacy criteria (LDL-C < 110 mg/dL or decreased ≥30% from baseline) were not met at week 4. Primary outcomes were safety and efficacy.

RESULTS

Twenty-eight youth initiated atorvastatin; 7 were 10-15 years and 21 were 15-24 years. Mean baseline LDL-C was 161 mg/dL (standard deviation 19 mg/dL). Efficacy criteria were met at week 4 by 17 of 27 (63%) participants. Atorvastatin was increased to 20 mg in 10 participants. Mean LDL-C decreased from baseline by 30% (90% confidence interval: 26%, 35%) at week 4, 28% (90% confidence interval: 23%, 33%) at week 24 and 26% (90% confidence interval: 20%, 33%) at week 48. LDL-C was less than 110 mg/dL in 44% at week 4, 42% at week 12 and 46% at weeks 24 and 48. Total cholesterol, non high-density lipoprotein (non-HDL)-C and apolipoprotein B decreased significantly, but IL-6 and high-sensitivity C-reactive protein did not. Two participants in the younger age group discontinued study for toxicities possibly related to atorvastatin.

CONCLUSIONS

Atorvastatin lowered total cholesterol, LDL-C, non HDL-C and apolipoprotein B in HIV-infected youth with ART-associated hyperlipidemia. Atorvastatin could be considered for HIV-infected children with hyperlipidemia, but safety monitoring is important particularly in younger children.

Sensitivity of blood lipids to changes in adiposity, exercise, and diet in children

PURPOSE

This study aims to determine whether blood lipids in healthy preadolescent children are sensitive to normally occurring changes in percent body fat, physical activity (PA), cardiorespiratory fitness (CRF), and macronutrient intake.

METHODS

Repeated measurements of fasting serum LDL cholesterol, HDL cholesterol, and triglycerides (TG); percent body fat (dual-energy x-ray absorptiometry); PA (pedometers); CRF (multistage run); and carbohydrate, sugar, and fat intake (dietary recall and record) were carried out in 469 children (51% girls) age 8, 10, and 12 yr.

RESULTS

Longitudinal relationships in boys showed that, for every one-unit increase in percent body fat, there was a 1.3% (95% CI, 0.9-1.8; P < 0.001) increase in LDL cholesterol; among girls, the increase was 0.8% (95% CI, 0.3-1.2; P = 0.003). In addition, we found a positive longitudinal relationship between TG and percent body fat (P < 0.001) in girls, and a negative longitudinal relationship between HDL cholesterol and percent body fat (P = 0.03) in boys. There were also longitudinal relationships between TG and CRF in both sexes (P < 0.05), but these were not sustained upon adjustment for percent body fat. Although cross-sectional relationships occurred in girls for both HDL cholesterol and TG with PA (P < 0.05), we found no evidence of any relationships between lipids and fat or sugar intake. By age 12 yr, LDL cholesterol was elevated (>3.36 mmol·L) in 16% and 20% of girls and boys, respectively.

CONCLUSIONS

Blood lipids in preadolescent children appear sensitive to normal changes occurring in their percent body fat and, thus, fitness. Our data support early attention to body composition in community strategies designed to prevent cardiovascular disease in later life.

[Idiopathic Nephrotic Syndrome: recommendations of the Nephrology Branch of the Chilean Society of Pediatrics. Part two]

Idiopathic nephrotic syndrome is the most common glomerular disease in childhood, affecting 1 to 3 per 100,000 children under the age of 16. It most commonly occurs in ages between 2 and 10. Its cause is unknown, and its histology corresponds to minimal change disease in 90% of cases, or focal segmental glomerulosclerosis. Steroid-resistant nephrotic syndrome represents 10-20% of idiopathic nephrotic syndrome in pediatrics. It has a poor prognosis, and its management is a significant therapeutic challenge. Half of patients evolve to end-stage renal disease within 5 years, and are additionally exposed to complications secondary to persistent NS and to the adverse effects of immunosuppressive therapy. The primary goal of treatment is to achieve complete remission, but even a partial remission is associated with a better renal survival than the lack of response. This paper is the result of the collaborative effort of the Nephrology Branch of the Chilean Society of Pediatrics with aims at helping pediatricians and pediatric nephrologists to treat pediatric idiopathic nephrotic syndrome. In this second part, handling of steroid-resistant nephrotic syndrome as well as nonspecific therapies are discussed.

A clinician's guide to statin drug-drug interactions

The statins are widely used worldwide to reduce risk for cardiovascular events in both the primary and secondary prevention settings. Although generally quite safe, the statins can be associated with a variety of serious side adverse effects, including myalgia, myopathy, and changes in plasma enzymes of hepatic origin. Although rare, the most serious of these is rhabdomyolysis. Several drugs can interfere with the metabolism and disposal of the statins, thereby increasing risk for adverse events. It is important that clinicians treating patients with statins be aware of the potential for drug-drug interactions between each statin and specific other drugs and take measures to prevent them. The prediction of potential drug-drug interactions derives from basic pharmacokinetic principles. Certain drug interactions are predicted by measuring the effect of interacting drugs on blood plasma concentrations of the statin. Individual patient variations resulting in part from polymorphisms in the metabolizing enzymes confound some of these predictions. Based on these known effects, a new classification for predicting statin drug interactions is proposed. This report discusses likely prescription and nonprescription interactions as well as potential alternatives for special populations.

Statin use in Australian children: a retrospective audit of four pediatric hospitals

AIM

The aim of this study was to perform an audit of the use of statins in Australian pediatric hospitals.

METHODS

A retrospective audit of patients prescribed statins during a visit to a pediatric hospital, as in- or outpatients, was performed in four major children's hospitals in three Australian states. Patients were identified through hospital pharmacy dispensing records. Statin use (dose, type) as well as medical history was recorded.

RESULTS

A total of 157 patients under the age of 18 were included in the audit. The most common reasons for being prescribed a statin included history of organ transplantation, renal disease and familial hypercholesterolemia (FH). Four statins were prescribed: atorvastatin (n = 77), pravastatin (n = 45), simvastatin (n = 25) and rosuvastatin (n = 10). All statins, apart from rosuvastatin, were used in very young children (1-7 years old). Polypharmacy was common in these patients, including combinations with calcineurin inhibitors and diltiazem, which can increase systemic statin exposure. A small number of very young children were prescribed high doses of statin, based on mg/kg dosing.

CONCLUSIONS

Statins were prescribed to children younger than suggested by current Australian guidelines, with atorvastatin being the preferred statin of choice. Long-term safety studies on the use of statins in children have only included FH patients so far, who are generally healthy besides their raised lipid levels. Further long-term safety studies are needed to include the more vulnerable transplant and renal patients, identified in this audit as being prescribed statins. This can help formulate guidelines for the safest possible use of this class of drugs in the pediatric setting, including the possibility of weight-based recommendations for younger children.