Using pediatric cholesterol guidelines for teens, young adults would increase statin use
Application of pediatric guidelines for lipid levels for persons 17 to 21 years of age who have elevated low-density lipoprotein cholesterol (LDL-C) levels would result in statin treatment for more than 400,000 additional young people than the adult guidelines, according to an article published online by JAMA Pediatrics.
Adolescence is a common time for the emergence of risk factors for cardiovascular disease, including abnormal cholesterol levels. The 2011 National Heart, Lung, and Blood Institute Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents and the 2013 American College of Cardiology and American Heart Association Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults differ in their recommendations regarding statin use. Because 17 to 21 years is a typical age for transition from pediatric to adult-centered care, these disparate approaches may lead to confusion in clinical practice, according to background information in the article.
Holly C. Gooding, M.D., M.Sc., of Boston Children's Hospital, and colleagues compared the proportion of young people 17 to 21 years of age who meet criteria for pharmacologic treatment of elevated LDL-C levels under pediatric vs adult guidelines. The researchers used data from the National Health and Nutrition Examination Survey (NHANES). Surveys were administered from January 1999 through December 2012, and the analysis was performed from June through December 2014.
Of the 6,338 persons 17 to 21 years of age in the NHANES population included in this analysis, 2.5 percent would qualify for statin treatment under the pediatric guidelines compared with 0.4 percent under the adult guidelines. Extrapolating to the U.S. population of 20.4 million people age 17 to 21 years, 483,500 individuals would be eligible for statin treatment under the pediatric guidelines compared with 78,200 under the adult guidelines, a difference of about 400,000. The authors note that the actual number treated is likely to be much lower owing to less than universal screening in this age group, challenges with adherence to medication regimens, and physician or patient disagreement with the recommendations.
Participants who met pediatric criteria had lower average LDL-C levels (167 vs 210 mg/dL) but higher proportions of other cardiovascular risk factors, including hypertension, smoking, and obesity compared with those who met the adult guidelines.
"Given the current uncertain state of knowledge and conflicting guidelines for treatment of lipid levels among youth aged 17 to 21 years, physicians and patients should engage in shared decision making around the potential benefits, harms, and patient preferences for treatment. The 2013 American College of Cardiology and American Heart Association guidelines recommend shared decision making with patients for whom data are inadequate, including young people with a high lifetime risk for atherosclerotic cardiovascular disease. Patients and clinicians should clearly address other modifiable risk factors, including optimizing diet, exercise, and weight and promoting abstinence from tobacco, as strongly recommended by both the pediatric and adult guidelines," the researchers conclude.