Hyperlipidemia in the

Pediatric Population

Prepared and Presented by

Jon Manocchio, Pharm D Blanchard Valley Hospital

January 2012

Introduction

• Hyperlipidemia in the pediatric population is an ever growing problem

• Healthcare needs to be evaluated in order to meet the needs of these patients

• Many contributing factors are present in patients – Development

– Screening and diagnosis

– Treatment

• Careful monitoring and treatment regimens are important

Atherosclerosis

• Definition

• Progression – Hyperlipidemia

• Primary – Genetic abnormalities

• Secondary – Begins in childhood

» Based on risk factors

• Consequences

Lipid Trends in Pediatrics

0

20

40

60

80

100

120

140

Age

Lipid Level

Hyperlipidemia Pathophysiology

• Prevalence

• Development

• Predictor

• Implications

Hyperlipidemia in Pediatrics

• Obesity

– Body Mass Index (BMI)

• 95th percentile

• 85-95th percentile

– Increasing prevalence

– Continues into adulthood

– At risk for developing complications

Cardiovascular Complications

• Secondary to obesity – Hypertension

– Hyperlipidemia

– Diabetes Mellitus

– Metabolic Syndrome • Larger waist line

• Elevated triglyceride level

• Decreased HDL cholesterol

• Hypertension

• Elevated fasting glucose

Screening for Hyperlipidemia

• Recommendations – Birth – 2 years old

• No screening – Grade C

– 2 years – 8 years old • No routine screening – Grade B

• Fasting lipid panel (FLP) x 2

– 9 years – 11 years old • Universal screening – Grade B

• Fasting vs. Non-fasting

Screening for Hyperlipidemia

• Recommendations

– 12 years – 16 years old

• No routine screening – Grade B

• Fasting lipid panel (FLP) x 2

– 17 years – 21 years old

• Universal screening – Grade B

– Adulthood

• Universal screening annually

The Debate

Proponent To Screening • Pediatrics with elevated lipids

warrant treatment

• Pediatrics with FH may not be evaluated because their parents have yet to show symptoms

• Relying on solely a family history for screening of pediatrics missed nearly 30-60% of pediatrics with lipid disorders

• Identification of disorders will spur lifestyle modifications to prevent complications

Opponent To Screening • Clinical significance of hyperlipidemia is

not known in pediatrics

• Pharmacotherapy has not been studied in the pediatric population for secondary hyperlipidemia

• Long term effects of statins are unknown

• Fear that lifestyle modifications will be forgone due to ease of oral medications

• Recommendations are inconsistent with the USPSTF recommendations

• Identification of pediatrics with hyperlipidemia will not guarantee that they will change their lifestyle

Dietary Management

• Monitor – Calories from fat

• Saturated fat

• Monounsaturated fat

– Cholesterol

– Trans fat

– Simple sugars

• Supplement – Plant sterols/stanols esters

– Psyllium

– Increase omega-3 fatty acids

Physical Activity

• Non-obese pediatrics

– Moderate-vigorous physical activity

– Limiting screen time

• Obese pediatrics

– Beyond recommendation made for non-

obese pediatrics

Pharmacologic Options

• Bile Acid Sequestrants – Mechanism

– Side effects

– Agents • Cholestyramine (Questran)

– 240mg/kg/day in divided doses

• Colestipol (Colestid) – 10g daily or 5g BID

• Colesevelam (Welchol) – 3.75g daily or 1.875g BID

Pharmacologic Options

• Statins

– Mechanism

– Safety

– Side effects

– Monitoring

Pharmacologic Options

• Statins – Agents

• Atorvastatin (Lipitor) – 10-20mg daily (maximum 20mg)

• Fluvastatin (Lescol) – 20-80mg daily (maximum 80mg)

• Lovastatin (Mevacor) – 10-40mg daily (maximum 40mg)

• Pravastatin (Pravachol) – 20-40mg daily (maxiumum 20-40mg depending on age)

• Rousuvastatin (Crestor) – 5-20mg daily (maxiumum 20mg)

• Simvastatin (Zocor) – 10-40mg daily (maxiumum 40mg)

Pharmacologic Options

• Combination – Bile Acid Sequestrants

– Statins

• Other options – Niacin

– Fibrates

– Fish Oil

– Cholesterol absorption inhibitors

Treatment Based on Age

• Pediatrics

– Birth – 10 years old

• Avoid pharmacologic therapy

– 10 years – 20 years old

• Decision based on results of screening

– LDL > 250 or TG > 500

– LDL < 250 and TG < 500

» Specific therapies based on lipid levels and

associated conditions

Recommendation

• Decisions will vary

– Based on clinicians

– Based on patients

– Based on family

• Personal recommendation

Conclusion

• Pediatrics are experiencing more adult diseases due to increasing obesity, among other factors

• Therapies aimed at treating pediatrics have not been fully studied or understood

• Screening for hyperlipidemia is a topic of controversy in the pediatric population

• Each clinician must make decisions based on each specific patient

• Monitoring and follow-up are critical during treatment

Questions?

References

• Haney EM, Huffman LH, Bougatsos C, et al. Screening and treatment for lipid disorders in children and adolescents: Systematic Evidence Review for the US Preventive Services Task Force. Pediatrics. 2007; 120(1): e189-e214.

• National Heart, Lung, and Blood Institute. Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents: Summary Report (2011). http://nhlbi.nih.gov/guidelines/cvd_ped (Accessed December 28, 2011).

• PL Detail-Document, Treatment of Hyperlipidemia in Children and Adolescents. Pharmacist’s Letter/Prescriber’s Letter. January 2012.

• Rader D.J., Hobbs H.H. (2012). Disorders of Lipoprotein Metabolism. In D.L. Longo, D.L. Kasper, J.L. Jameson, A.S. Fauci, S.L. Hauser (Eds), Harrison's Principles of Internal Medicine, 18e. Retrieved January 5, 2012 from http://0-www.accesspharmacy.com.polar.onu.edu/content.aspx?aID=9143689.

• Spiotta RT and Luma GB. Evaluating obesity and cardiovascular risk factors in children and adolescents. Am Fam Physician. 2008; 78(9): 1052-58.

• Steiner MJ, Skinner AC, and Perrin EM. Fasting may not be necessary before lipid screening: A natinoal representative cross-sectional study. Pediatrics. 2011; 128: 463-70.