Statins and children: whom do we treat and when?

Although the debate about when, whom, and how to treat adults with elevated low-density-lipoprotein cholesterol (LDLc) is essentially over because of a huge amount of data generated by large, clinical end-point, placebo-controlled trials with HMG CoA reductase inhibitors (statins),1–3 the issue in children and adolescents is not yet settled. In this issue of Circulation, Rodenburg and colleagues4 provide important further evidence for both the potential benefit of long-term LDLc reduction and the safety of treating children and adolescents with familial hypercholesterolemia (FH) with statins. This latest trial is an extension of an earlier doubleblind, placebo-controlled, 2-year study in just over 200 FH children 8 to 17 years of age at entry.5 The initial trial was the first demonstration that even a moderate reduction in LDLc of 25% to 30% resulted in a significant decrease in the rate of thickening of the carotid artery intima thickness and thus moved the focus of lipid-lowering therapy in children from a plasma marker to a well-established anatomic surrogate of atherosclerosis. In the present 2-year extension in which all children were treated with the statin, Rodenburg and colleagues demonstrate that the age at which statin treatment was started was positively associated with carotid artery intima thickness on follow-up and strongly argue that, on the basis of their data, when it comes to treating children with FH, “the earlier, the better.” This would by implication include children at least as young as 8 years of age, the entry age in their trial. This is a few years younger than all current recommendations, including the recently released scientific statement on drug therapy of high-risk lipid abnormalities in children and adolescents from the American Heart Association Atherosclerosis, Hypertension, and Obesity in Youth Committee, Council of Cardiovascular Disease in the Young,6 which states “In general, do not start [drug therapy] before 10 years of age in boys and preferably after onset of menses in girls. Patients should ideally be at Tanner stage II or higher.”