Are Pediatric Guidelines for Statins Too Aggressive?

If, instead of following the adult guidelines, doctors used pediatric guidelines to identify teens with high LDL-levels, and if universal screening was in place, another 400,000 adolescents would be taking statins. Would that increase be good or bad? Doctors disagree. Some suggest that the increased treatment would be premature and dangerous to teen health.  Results from a study, which used the Centers for Disease Control and Prevention’s National Health and Nutrition Examination Survey, published today in JAMA Pediatrics, found that about 2.5% of teens 17-21 would satisfy the pediatric statin guidelines, compared with 0.4% using adult criteria.

“The safety of statins [in this population] is completely speculative and theoretical,” said Rodney Hayward, MD, Director of the Robert Wood Johnson Clinical Fellows Program, at the University of Michigan Ann Arbor. “We really need good evidence of benefit before we take a risk like this with adolescents.”

What concerns Hayward is a trend for specialists, in this case, pediatric cardiologists, to favor aggressive treatment before the burden of proof is satisfied. “There is a tendency to view everything as safe until we have the new Vioxx.” The teen brain is still developing. Given associations between statins and cognitive problems, Hayward questions whether giving statins could have adverse neurologic effects. Statin’s effects on neurologic tissue are also concerning. It would be best if teens were physically active. Adverse muscle effects have also been identified with statin use. This is just at the time when you want kids to be physically active.

One possible exception for statin use that Hayward would use is an extremely high LDL level. He also acknowledged that there is some evidence that testing adolescents once every five years may derive benefit. Hayward still thinks that benefit would be gained if statins were begun later, perhaps at age 35.Statin benefits do not accrue until years later.

The authors urge doctors to use shared decision making in cases of uncertainty because people vary in what risks that they want to take. To my knowledge, no studies of shared decision making in evaluating whether or not to put your kids on statins have been done. I wonder whether prescribing pediatric cardiologists can present the knowns and unknowns without bias.

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