Dyslipidemias in children with Diabetes Mellitus is reported to be around 18%. However, the use of statins in children is controversial.
Diabetic patients are at increased risk of developing heart and renal diseases. Complications develop in diabetic patients after around ten to fifteen years.
Children with type 1 diabetes mellitus are more difficult to manage. Difficulties arise because of the marked fluctuations in their glucose control.
This is secondary to abnormal eating habits, irregular exercise and sports timings and non-adherence to treatment. This makes them at risk of developing these complications at an early age.
Efficacy of lipid-lowering drugs is well established in elderly patients. However, the use of statins in children with type 1 Diabetes Mellitus is a gray area.
What are statins and why are they important?
Statins are drugs that lower cholesterol levels in the blood. High cholesterol levels in the blood can cause vascular narrowing by the process of plaque formation.
Other factors important in plaque formation include vascular endothelial injury and platelet adhesion to the endothelium.
Since high cholesterol levels are of paramount importance in the formation of the atherosclerotic plaque, lowering them becomes vital in the prevention of heart diseases.
This, in turn, highlights the importance of lipid-lowering drugs in the prevention of heart diseases.
Why are there controversies in the use of statins in children?
Long term trials to evaluate lipid-lowering drugs in children is probably one of the most difficult interventions to study. Very few studies have evaluated the safety and efficacy of statins in children.
Compared to non-diabetics, children with diabetes are at increased risk of developing heart and atherosclerotic disease at an early age.
Similarly, the safety of statins in adults and youth with familial dyslipidemias has been proved.
Lastly “metabolic memory” plays a role in the prevention of cardiovascular diseases. All these factors influence the physicians to start lipid-lowering drugs in children with diabetes and dyslipidemias.
On the contrary, because of lack of data, medication cost, potential lifetime treatment and lack of data that early treatment with statins can regress the vascular lesions in diabetic children, statins use is not as popular in children as adults.
Current guidelines about statins use in children with type 1 Diabetes mellitus:
The American Diabetes Association has issued guidelines for screening and managing dyslipidemias in patients with type 1 Diabetes Mellitus which are as follows:
- Screening: Obtain a fasting lipid profile soon after the diagnosis of type 1 diabetes in children aged ten years or more.
- Repeat testing should be done at 3-5 yearly intervals if LDL-c is less than 100 mg/dl. In case LDL-c is greater than 100 mg/dl, annual screening is recommended.
- Management should start with optimizing glucose control and medical nutrition therapy. A diet containing up to 7% of total cholesterol has been used with little effect on growth.
- Children aged ten years or more with LDL-c of greater than 160 mg/dl should be given a statin. Those with LDL-C of less than 160 mg/dl but greater than 130 mg/dl and one or more cardiovascular risk factor should also be treated.
For children with significant family history of cardiovascular diseases, screening should start from as early as 2 years of age.
Statins are not approved for patients aged less than 10 years, and statin treatment should generally not be used in children with type 1 diabetes before this age.
Efficacy of statins in children with type 1 diabetes mellitus:
A recent trial evaluated the safety and efficacy of statins in adolescents. The trial reported a significant reduction in total cholesterol, LDL and triglyceride levels.
The primary efficacy outcome was the change in carotid intima-media thickness with the use of statins. The results did not show any improvement in vascular intima-media thickness.
The researchers suggested to follow the cohort of patients for incident cardiovascular diseases in the future.
In conclusion:
The use of statins in children with type 1 Diabetes Mellitus is controversial. The question of whether “the younger the better” or “later but greater” remains unanswered. However, screening may be initiated at the age of ten years or more. Those children at high risk (familial dyslipidemias) may be screened at an earlier age.
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