Statin Island?
No, that was not a misspelling, but a reference to the isolation and island mentality felt by many parents, as proclamations from on-high come down from the mount to tell us how to raise our children, and what is good for them. At one time, we thought we were the best judges of our own flesh and blood, and, now, organizations like the American Academy of Pediatrics (AAP) have usurped that God-given role. What are we talking about here? Hypercholesterolemia, or high blood cholesterol, in children. Why is this such a big deal? Because the AAP is now advocating pharmacologic treatment of high cholesterol in children, in order to head-off and reduce the risk of cardiovascular disease later in life. First it was Ritalin in children with Attention Deficit Hyperactivity Disorder (ADHD), then it was untested childhood vaccinations to interdict a legion of infectious diseases, and now it is even more and earlier pharmacologic therapy with drugs commonly known in layman’s jargon as statins, and more technically, as 3-hydroxy-3-methyl-glutaryl coenzyme A (HMG-CoA) reductase inhibitors. The latter intervene to block a crucial step in the synthesis of cholesterol in the liver. While they have been shown to be safe, and their side effects reasonable in adults (namely, muscle pain and an elevation of liver enzymes known as serum aminotransferases in the blood, a possible sign of liver damage), the effects of statins in children are virgin territory, if you’ll excuse the pun. Also, as cholesterol plays a key role in the brain, accounting for 25% of the total cholesterol stores in the body, and as at 8 years of age, a child’s brain is in a dynamic state of growth, development, and flux, pharmacologic therapy with statins at an early age may result in the opening of a neurologic Pandora’s box, whose long-term effects on the youth of the world may not only be devastating, but also not evident for years to come. That is why popular press and the media have been so eager to jump on this issue.
Let’s step back a bit, however. Hasn’t obesity been declared and coded as a disease of late, instead of a condition or a mere state of being? Hasn’t childhood obesity reached epidemic proportions in the U.S. and many parts of the world, with the prevalence of pediatric obesity tripling in the last 25 years and with the majority of some minority-group adolescents being overweight or obese? If that is, indeed, the case, and we believe it is, doesn’t the end justify the means? If increasing body weight in childhood is associated with cardiovascular risk in adulthood, as well as a plethora of other maladies in adolescence and adulthood, including type 2 diabetes mellitus, known to result in a complication cascade resulting in renal failure requiring dialysis, limb amputations, and even death before 30 years of age, perhaps we should not begrudge some clinicians, doctors of pharmacy, and public health professionals a proverbial stab in the dark. Risks and benefits will need to be weighed, as well as cost-effectiveness, and that will require time, further research, and unemotional objectivity. At this point in time, it is a little premature to say how this is going to go. Also, while pharmaceutical companies would be all too happy to include childhood statins in their cluster bombing of the television airwaves, along with the marketing of other “adult” drugs to children, their parents, and their educators, perhaps clinical and public health care expenditures would be better directed at lifestyle modification, via improved diet, increased exercise, and legal action to curtail fast-food advertising and to improve fast-food offerings. The stage is set for a long, drawn-out battle, with the AAP, pharmaceutical companies, and their political allies pitted against some pediatricians, public health professionals, school boards, nutritionists, kinesiologists, preventionists, and good old Mom and Dad.
With the new 2008 AAP recommendations on hypercholesterolemia calling for statins as first-line agents, an 8-year minimum age for pharmacotherapy, and a low-density lipoprotein (LDL, “bad cholesterol”) level of ≥ 130 mg per deciliter if diabetes mellitus is present, the walls are slowly closing in. No man is an island, however, even if drug companies would have us believe that our children and adolescents could better spend their time and health on a “statin island.” Only time will tell if island breezes prevail.
Let’s step back a bit, however. Hasn’t obesity been declared and coded as a disease of late, instead of a condition or a mere state of being? Hasn’t childhood obesity reached epidemic proportions in the U.S. and many parts of the world, with the prevalence of pediatric obesity tripling in the last 25 years and with the majority of some minority-group adolescents being overweight or obese? If that is, indeed, the case, and we believe it is, doesn’t the end justify the means? If increasing body weight in childhood is associated with cardiovascular risk in adulthood, as well as a plethora of other maladies in adolescence and adulthood, including type 2 diabetes mellitus, known to result in a complication cascade resulting in renal failure requiring dialysis, limb amputations, and even death before 30 years of age, perhaps we should not begrudge some clinicians, doctors of pharmacy, and public health professionals a proverbial stab in the dark. Risks and benefits will need to be weighed, as well as cost-effectiveness, and that will require time, further research, and unemotional objectivity. At this point in time, it is a little premature to say how this is going to go. Also, while pharmaceutical companies would be all too happy to include childhood statins in their cluster bombing of the television airwaves, along with the marketing of other “adult” drugs to children, their parents, and their educators, perhaps clinical and public health care expenditures would be better directed at lifestyle modification, via improved diet, increased exercise, and legal action to curtail fast-food advertising and to improve fast-food offerings. The stage is set for a long, drawn-out battle, with the AAP, pharmaceutical companies, and their political allies pitted against some pediatricians, public health professionals, school boards, nutritionists, kinesiologists, preventionists, and good old Mom and Dad.
With the new 2008 AAP recommendations on hypercholesterolemia calling for statins as first-line agents, an 8-year minimum age for pharmacotherapy, and a low-density lipoprotein (LDL, “bad cholesterol”) level of ≥ 130 mg per deciliter if diabetes mellitus is present, the walls are slowly closing in. No man is an island, however, even if drug companies would have us believe that our children and adolescents could better spend their time and health on a “statin island.” Only time will tell if island breezes prevail.
© 2008, Albert M. Balesh, M.D. All rights reserved.
posted by Dr. Al at
11/06/2008 02:57:00 AM
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