Disclosures. Pediatric Dyslipidemia Casey Elkins, DNP, NP C, CLS, FNLA. Learning Objectives. Atherogenesis. Acceptable Values

Transcription

1 39 th National Conference on Pediatric Health Care Pediatric Dyslipidemia Casey Elkins, DNP, NP C, CLS, FNLA March 19-22, 2018 CHICAGO Disclosures Speakers Bureau Sanofi and Regeneron Learning Objectives Atherogenesis Identify current guidelines in the treatment of pediatric dyslipidemia. Discuss current pharmacological treatment options for pediatric dyslipidemia. Discuss current non pharmacological treatment options for pediatric dyslipidemia. Adapted from Pepine CJ. Am J Card. 1998; 82(supp 10A):23S 27S Expected Lipids in Children and Adolescents Acceptable Values 1

2 Screening? Genetic and acquired dyslipidemia Risk factor tracking from childhood to adulthood Lowering LDL C and lifetime risk of ASCVD Focused Screening In children 2 18 y/o Parents have high cholesterol or are on meds Family hx of premature ASCVD in 1 st degree relative Less than 55 y/o in men Less than 65 y/o in women Unknown family hx Once between ages 9 11 y/o Repeat screening at 20 y/o Universal Screening Benefits of Universal Screening Identify hefh children (1:300) Identify parents and other adults with hefh through Cascade Screening Identify abnormal lipid panels in over 20% of peds pts Motivational benefits for lifestyle changes Bright Futures/AAP Recommendations for preventive Pediatric Health Care Nordestgarrd BG, et al. European Heart Journal 2013; 34(45): Kit BK et al JAMA Pediatr. 2015: 169(10:e1 e8 Acceptable Values Lipid Goals Non HDL C is a better predictor of ASCVD than LDL C Use lipid precentiles Srinivasan SR, Frontini MD, Xu J, Berenson GS. Utility of childhood non high density lipoprotein cholesterol levels in predicting adult dyslipidemia and other cardiovascular risk: the Bogalusa Heart Study. Pediatrics. 2006;118: Frontini MG, et al Usefulness of childhood non high density lipoprotein cholesterol levels versus other lipoprotein measures in predicting adult subclinical atherosclerosis: the Bogalusa Heart Study. Pediatrics. 2008; 121:

3 ASCVD Risk Factors Lowering Risk Atherosclerotic lesions may begin in childhood Rarely symptomatic until the 4 th or 5 th decade of life ASCVD is leading cause of morbidity and mortality Those at high risk due to genetics or lifestyle will benefit from earlier treatment Treated angina Myocardial infarction PCI CABG Ischemic CVA Family History Testing Mechanisms Fingerstick or venipuncture Fasting or Non fasting Non HDL C 145 mg/dl followup 2 fasting lipid profiles Average results Selective Screening Did not prove to be effective Inaccurate/ incomplete family histories Reverse Cascade Screening Screen all first degree relatives of a child with FH Adults at greater short term risk Haney EM, Huffman LH, Bougatsos C, et al. Screening for lipid disorders in children and adolescents: systematic evidence review for the U.S. Preventive Services Task Force. Evidence Synthesis Number 47 Prepared for the Agency for Healthcare Research and Quality EF 1 3

4 Familial Hypercholesterolemia Familial Hypercholesterolemia Autosomal Recessive Heterozygous (HeFH) 1:300 Homozygous (HoFH) 1:1,000,000 Secondary Dyslipidemia Lifestyle Modifications Dietary Modifications 25 30% total fat 7% saturated fat < 200 mg cholesterol Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents. National Heart, Lung, and Blood Institute. Expert panel on integrated guidelines for cardiovascular health and risk reduction in children and adolescents: summary report. Pediatrics. 2011;128(Suppl 5): S213 S256. Lifestyle Modifications Dietary Modifications with elevated triglycerides/ obesity Reduce refined carbohydrates Reduce refined sugars Decreased total calories Lifestyle Modifications Physical Activity 60 minutes moderate or high intensity activity daily Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents. National Heart, Lung, and Blood Institute. Expert panel on integrated guidelines for cardiovascular health and risk reduction in children and adolescents: summary report. Pediatrics. 2011;128(Suppl 5): S213 S256. 4

5 LDL C > 190 mg/dl who do not respond to lifestyle mgmt. Other high risk patients LDL C 160 mg/dl 190 mg/dl with Risk Factors Hypertension Tobacco Use Obesity, etc. Statins Good safety profile Category X Greatest effect of lowering LDL C Improvement in early atherosclerosis markers < endothelial dysfunction cimt reduction Statins Adverse Effects Muscle symptoms Elevated liver enzymes Hyperglycemia Statins Lab monitoring Lipid panel Fasting glucose or A1c Liver enzymes Creatine kinase Rosenson RS, Baker SK, Jacobson TA, Kopecky SL, Parker BA. The National Lipid Association s Muscle Safety Expert Panel. An assess ment by the Statin Muscle Safety Task Force: 2014 update. J Clin Lipidol. 2014;8(3 Suppl):S58 S71. Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents. National Heart, Lung, and Blood Institute. Expert panel on integrated guidelines for cardiovascular health and risk reduction in children and adolescents: summary report. Pediatrics. 2011;128(Suppl 5): S213 S256. Pravastatin 8 13 y/o (20mg), y/o (40mg) Atorvastatin y/o (10 20mg) Rosuvastatin 8 9 y/o (10mg), y/o (20mg) Lovastatin y/o (40mg) Simvastatin y/o (10 40mg) Fluvastatin y/o (80mg ER) Pitavastatin No pediatric indication Bile Acid Sequestrants Primary A/E are GI related Can be managed with dietary fiber and fluids 5

6 Colesevlam y/o males and postmenarchal females (3.75 gm) Colestipol no peds indication Cholestyramine 6 12 y/o (80 mg/kg tid), adolescents 4gm bid Cholesterol absorption inhibitor Relatively safe Little pediatric data Vuorio A, Doherty KF, Humphries SE, Kuoppala J, Kovanen PT. Statin treatment of children with familial hypercholesterolemia trying to balance incomplete evidence of long term safety and clinical accountability: are we approaching a consensus? Atherosclerosis 2013;226: No sufficient evidence Based on clinical judgement 50% reduction in LDL C Upper limits of normal Non HDL C 144 mg/dl LDL C 129 mg/dl Targets of Therapy Daniels SR, Gidding SS, de Ferranti SD, National Lipid Association Expert Panel on Familial Hypercholesterolemia. Pediatric aspects of familial hypercholesterolemias: recommendations from the National Lipid Association Expert Panel on Familial Hypercholesterolemia.J Clin Lipidol. 2011;5(3 Suppl):S30 S37. Watts GF, Gidding S, Wierznicki AS, et al. Integrated guidance on the care of familial hypercholesterolemia from the International FH Foundation. J Clin Lipidol. 2014;8: