In July, the American Academy of Pediatrics (AAP) updated its guidelines for managing high cholesterol in children. The revisions generated a blizzard of media attention that surprised many in the pediatrics community.
After all, the revisions were for the most part incremental compared with previous iterations: slightly more comprehensive screening, an emphasis on the quality of fat intake rather than total fat intake, and a reduction in the recommended age for initiating drug therapy from 10 to 8 years.
There was one thing though, that was not incremental. The AAP now recommends statins as potential first-line cholesterol-lowering drugs for kids in whom efforts to lose weight and exercise fail to sufficiently reduce high cholesterol level. The older version made no mention of statins and recommended bile acid-binding drugs instead.
The bile acid binders don’t work well and are poorly tolerated. Statins work exceedingly well and are well tolerated in adults. The problem is that there is only limited, short-term data showing statins are safe in kids. In selecting a drug to recommend, the AAP had to trade-off unknown long-term risks of statins vs. their clear superiority as cholesterol lowering agents.
Sales of statins are already in the billions and how exactly can we subject our kids to unknown risks like that? The reasons for the firestorm are clear.
Now, two Harvard clinicians have posited that the epidemic of childhood obesity is the larger contextual issue at work here. That is what drives unprecedented numbers of kids to the point where they need cholesterol-lowering drugs in the first place. And that is what forces pediatricians to use other powerful “adult” drugs like diuretics and beta blockers for high blood pressure, insulin sensitizers for metabolic syndrome, and even aspirin for coagulopathies that these kids end up with in addition to high cholesterol. We don’t know much about how these drugs work in kids, either.