Evaluation and management of hyperlipidemia in children and adolescents

Preventive cardiology for the aging population: how can we better design clinical trials of statins?

INTRODUCTION

Older adults form a fast-increasing proportion of the world population. However, gains in increasing quantity of life have not been accompanied by similar gains in quality of life. Older people frequently experience frailty, memory problems, and chronic diseases including cardiovascular disease (CVD) and neurodegenerative diseases. Recent trials have demonstrated the efficacy of anti-hypertensive therapy in older populations but failed to show benefits for aspirin.

AREA COVERED

Statins clearly reduce CVD events in middle-aged populations. There seems to be evidence that the effect is similar in primary prevention older populations based on meta-analyses mainly from sub-groups in large trials, but this becomes less clear with increasing age. However, given differences in drug metabolism and possibly efficacy, competing co-morbidities, their effects on mortality, disability, and dementia in this age group remain to be determined.

EXPERT OPINION

Two large trials are now underway to clarify the role of statin therapy in people aged over 70 years using endpoints of mortality, disability, and neurocognitive endpoints as well as standard cardiovascular disease outcomes. They may provide also provide more evidence on how to approach the over 80 year age group.

The impact of TNF-α 308G>A gene polymorphism on children's overweight risk and an assessment of biochemical variables: A cross-sectional single-center experience

INTRODUCTION

The aim of this study was to assess the role of TNF-α 308 G>A gene polymorphism in children's overweight risk so as to correlate this polymorphism with anthropometric and biochemical variables.

MATERIALS AND METHOD

A cross-sectional study was carried out on 188 Romanian children ages 5-18 years, who were classified into controls (Group 1; n = 109) and overweight children (Group 2; n = 79).

RESULTS

Higher values of MUAC and TST (p < 0.001) were obtained in the overweight group. A significant association was found between TNF-α 308 G>A polymorphism and weight status in the studied population (p = 0.009). There was also a positive association between the variant genotypes (GA or AA) of TNF-α 308G>A gene polymorphism and weight status, which was more frequently found among normal weight than overweight children (74.5% versus 25.5%, respectively). The final logistic multivariable included five independent variables (TNF-α genotype, gender, cholesterol, ASAT, and ALAT), which were statistically significant predictors with negative/positive effects on children's overweight risk; this model explained 30% of the variance in the outcome variable.

CONCLUSION

The variant genotype of TNF-α 308G>A gene polymorphism was more frequent among normal weight children. In the presence of other covariates, such as age, gender, cholesterol, LDL cholesterol, ALAT, and glycemia, the TNF-α 308 G>A gene polymorphism remained an independent protective factor for children's overweight status.

Molecular aspects of hypercholesterolemia treatment: current perspectives and hopes

Hypercholesterolemia is a pathological condition which has been reported in 39% of the worlds' adult population. We aimed to review molecular aspects of current and novel therapeutic approaches based on low-density lipoprotein cholesterol lowering strategies. Pathogenic mutations in the LDLR, ApoB, PCSK9 and LDLRAP genes cause deficient clearance of circulating low-density lipoprotein cholesterol particles via hepatic LDL receptor. This leads to increased plasma LDL cholesterol levels from birth, which can cause LDL depositions in the arterial walls. Ultimately, it progresses to atherosclerosis and an increased risk of premature cardiovascular diseases. Currently, statins, Ezetimibe, Bile acid sequestrants and PCSK9 inhibitors are the main therapeutic agents for the treatment of hypercholesterolemia. Moreover, novel RNA-based therapy had a strong impact on therapeutic strategies in recent decades. Additional development in understanding of the molecular basis of hypercholesterolemia will provide opportunities for the development of targeted therapy in the near future. Key Messages The most common genes involved in hypercholesterolemia are LDLR, PCSK9 and ApoB. Pharmacogenetic effects are typically constrained to pathways closely related to the pharmacodynamics and pharmacokinetics. Change in lifestyle and diet along with treatment of the underlying disease and drug therapy are the current therapeutic strategies.

Studies on the regulation of lipid metabolism and its mechanism of the iridoids rich fraction in Valeriana jatamansi Jones

Valeriana jatamansi Jones, a plant with heart-shaped leaves in the Valeriana genus of Valerianaceae, is widely used in Chinese folk medicine. Iridoid is an important constituent of V. jatamansi that contributes to the pharmacological efficacy of the herb. This study aims to investigate the regulation of lipid metabolism and its mechanism of the iridoids rich fraction in V. jatamansi (IRFV). A high fat diet was used to establish the hyperlipidemia rat model, with 2mg/kg/d of simvastatin as a positive control, fed with 7.5, 15, and 30mg/kg/d of IRFV for 20days to investigate the lipid regulation activity and mechanism of IRFV. Body weight, liver index, total cholesterol (TC), triglyceride (TG), low-density lipoprotein cholesterol (LDL-C), and high-density lipoprotein cholesterol (HDL-C) in both serum and liver, as well as total bile acid (TBA), aspartate aminotransferase (AST), and alanine aminotransferase (ALT) in serum were measured. The lipoprotein lipase (LPL) and hepatic lipase (HL) activities and the apoprotein A5 (ApoA5), peroxisome proliferator-activated receptor α (PPAR-α), sterol regulatory element-binding proteins (SREBP-1c), and liver X receptor α (LXR-α) protein expressions were observed. Liver pathology was described through hematoxylin-eosin (HE) staining. Compared with the model group, three different IRFV dosages can slow down the weight gain of rats, reduce the contents of TG, and increase the contents of HDL-C in serum. Low IRFV dosage can significantly reduce the AST and ALT contents in serum, liver index, and the TG contents in liver, enhance LPL activity. Medium IRFV dosage can significantly decrease the TG and LDL-C contents in liver. High IRFV dosage can significantly reduce LDL-C, TBA, AST, and ALT contents in serum, and enhance HL activity. Three different IRFV dosages can significantly increase the ApoA5 and PPAR-α protein expression and decrease the SREBP-1c protein expression. Furthermore, the LXR-α protein expression decreased in low- and high-dose groups. Liver tissue pathological observation showed that IRFV can improve cell degeneration to a certain extent. These results strongly suggest that IRFV play significant roles in regulating lipid metabolism, the mechanism may be related to the increased ApoA5 protein expression.

Correlations Between Leptin Gene Polymorphisms 223 A/G, 1019 G/A, 492 G/C, 976 C/A, and Anthropometrical and Biochemical Parameters in Children With Obesity: A Prospective Case-Control Study in a Romanian Population-The Nutrichild Study

The aim of this study was to establish the manner in which the LEPR 223, 1019, 492, and 976 gene polymorphisms influence child obesity.We performed a prospective case-control study on 264 hospitalized children from Romania (Nutrichild study) whom we divided into 2 groups: Group I -143 controls and Group II-121 obese children.The 2 groups were evaluated regarding the anthropometry (MUAC, TST, H/L, hip, and abdominal circumference), paraclinical results (protein, leptin, adiponectin, TNF alfa, IL 6, IL 8, VEGF, protein, albumin) and LEPR 223, 1019, 492, and 976 gene polymorphisms. We noticed that the most frequent genotypes in obese children were AG+GG for LEPR 223 gene (P = 0.0001) and GA+AA for LEPR 1019 gene (P = 0.0001), whereas LEPR 492 and LEPR 976 gene polymorphisms did not correlate with obesity. MUAC, TST, H/L, leptin, and adiponectin were correlated with the GG genotype of the LEPR 223 gene, whereas the AG genotype correlated with TNF alpha and serum IL 8. Hip and abdominal perimeters were higher in LEPR 1019 AA genotype carriers, whereas TNF alpha and IL 6 correlated with the GG genotype of the same gene. Obesity did not correlate with protein serum levels.We observed that obesity is more frequent in children with LEPR 223 AG+GG and LEPR 1019 GA+AA genotypes. In obese children LEPR 223/492/1019 AG/GG/GA, GG/GG/GA and AA/GG/GA combined genotypes are more frequent.

Novel insights on the treatment of hypercholesterolemia

The diagnosis of dyslipidemia is increasing both in adulthood and in childhood because of not only the steadily increasing prevalence of obesity but also a rise of medical attention in detecting unfavorable genetic conditions in patients of all ages. Attempts in lifestyle changes are frequently failing and thus the pharmacological treatment of dyslipidemia is spreading in medical practice to reduce cardiovascular risk. In childhood, statins are authorized by 8 years of age. Nevertheless, data on their long-term safety and efficacy are still lacking, especially in ones with high cardiovascular risk and/or primary dyslipidemia such as homozygous familial hypercholesterolemia, considerable as a mainly exclusively pediatric disease. Thus, new pharmacological approaches are needed and have to be evaluated in all categories of patients. In this context, the update and the critical revision of new medications have become a new duty for scientists and clinicians.

Familial hypercholesterolemia: A review

Familial hypercholesterolemia (FH) is a genetic disorder of lipoprotein metabolism resulting in elevated serum low-density lipoprotein (LDL) cholesterol levels leading to increased risk for premature cardiovascular diseases (CVDs). The diagnosis of this condition is based on clinical features, family history, and elevated LDL-cholesterol levels aided more recently by genetic testing. As the atherosclerotic burden is dependent on the degree and duration of exposure to raised LDL-cholesterol levels, early diagnosis and initiation of treatment is paramount. Statins are presently the mainstay in the management of these patients, although newer drugs, LDL apheresis, and other investigational therapies may play a role in certain subsets of FH, which are challenging to treat. Together these novel treatments have notably improved the prognosis of FH, especially that of the heterozygous patients. Despite these achievements, a majority of children fail to attain targeted lipid goals owing to persistent shortcomings in diagnosis, monitoring, and treatment. This review aims to highlight the screening, diagnosis, goals of therapy, and management options in patients with FH.

The safety of statins in children

Current American Academy of Pediatrics Guidelines recommended that statins should be considered as a first-line agent in children as early as 8 years of age. The aim of our work is to assess the safety of 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors in children with hypercholesterolaemia.

CONCLUSION

Controlled studies in children show that statin monotherapy is efficacious, well tolerated and safe in the short-time. Unfortunately, these studies have relatively short-term follow-up periods, and therefore, long-term safety remains unclear.

Screening for co-morbidity in 65,397 obese pediatric patients from Germany, Austria and Switzerland: adherence to guidelines improved from the year 2000 to 2010

OBJECTIVE

The aim of the study was to analyze the adherence to current guidelines for co-morbidity screening in overweight and obese pediatric patients participating in the Adipositas-Patienten-Verlaufsdokumentation (APV) initiative in three German-speaking countries.

METHODS

APV database: 181 centers from Germany, Austria and Switzerland, specialized in obesity care, contributed standardized, anonymous data of medical examinations from 65,397 patients performed between 2000 and 2010. Completeness of screening for hypertension, dyslipidemia, and impaired glucose metabolism was analyzed using adjusted means.

RESULTS

Mean age of the cohort was 12.5 ± 2.9 years and 46.5% were male. 17.3% were overweight (>90th-97th percentile), 45.1% obese (>97th-99.5th percentile), and 37.7% extremely obese (>99.5th percentile). In 2000, blood pressure was documented for 55.1% of patients, increasing to 88.7% in 2010. The rate of lipid diagnostics also improved from 45.0 to 67.7%, and screening for diabetes rose from 32.7 to 62.3% in the same time period. Blood pressure measurements were performed more often during inpatient care (88.5%) compared to outpatient programs (77.5%). Screening was more complete with increasing age and increasing degree of obesity. In boys screening rate was higher than in girls.

CONCLUSION

During the 11-year period, screening for co-morbidity improved significantly in overweight or obese children and adolescents. However, adherence to guidelines is still insufficient in some institutions. Quality control based on benchmarking may improve obesity care and outcome.

Medication Use for Hypercholesterolemia in the Pediatric Population

The past few decades have shown an increase in the prevalence of chronic conditions in the pediatric population. One of the chronic conditions that appears to be on the rise in this population is hypercholesterolemia. At the same time, the rate of obesity is increasing in children and adolescents and may be putting our youth at risk for abnormal lipid levels. First-line prevention and treatment should involve intensive lifestyle medicine therapy. If warranted, however, the use of medications may be started as early as 8 years of age, but this has many unknown variables related to safety and efficacy. Caution and vigilant observation for drug interactions and adverse events is warranted by the health care team and family members throughout treatment with drug therapy.

Management of familial hypercholesterolaemia in children and adolescents

Familial hypercholesterolaemia is a disorder of low-density lipoprotein (LDL) cholesterol metabolism, which is associated with the onset of vascular changes associated with coronary heart disease in childhood. This disorder has co-dominant transmission with a prevalence of one in 500 in the general population. Cascade screening is the most effective method of identifying children. Children in the at-risk group should have their cholesterol levels checked between the age of 2 and 10 years. Children with LDL cholesterol levels ≥ 3.4 mmol/L are likely to suffer from this disorder, although at this level there is a significant false positive rate. Molecular genetic testing is available for the LDL receptor gene, APOB gene and the PCSK9 gene. This is the most specific test for familial hypercholesterolaemia but has a false negative rate of 20-50%. Once diagnosed, treatment should be considered in children with an LDL cholesterol level ≥ 4.9 mmol/L. If the child has two other risk factors or a positive family history, this threshold should be lowered to ≥4.1 mmol/L. Guidelines recommend that treatment should be commenced by the age of 10 years, although some advise waiting until menarche in females. Statin therapy is currently recommended as first line treatment. Randomised placebo trials have shown that statin therapy reduces LDL cholesterol levels by 25% and is not associated with increased risk of adverse events. These are short-term studies, and longer follow-up will be required to definitively prove efficacy and safety.

Considering statins for cholesterol-reduction in children if lifestyle and diet changes do not improve their health: a review of the risks and benefits

Children who appear healthy, even if they have one or more recognized cardiovascular risk factors, do not generally have outcomes of cardiovascular or other vascular disease during childhood. Historically, pediatric medicine has not aggressively screened for or treated cardiovascular risk factors in otherwise healthy children. However, studies such as the P-Day Study (Pathobiological Determinants of Atherosclerosis in Youth), and the Bogalusa Heart Study, indicate that healthy children at remarkably young ages can have evidence of significant atherosclerosis. With the increasing prevalence of pediatric obesity, can we expect more health problems related to the consequences of pediatric dyslipidemia, hypertriglyceridemia, and atherosclerosis in the future? For many years, medications have been available and used in adult populations to treat dyslipidemia. In recent years, reports of short-term safety of some of these medications in children have been published. However, none of these studies have detailed long-term follow-up, and therefore none have described potential late side-effects of early cholesterol-lowering therapy, or potential benefits in terms of reduction of or delay in cardiovascular or other vascular end-points. In 2007, the American Heart Association published a scientific statement on the use of cholesterol-lowering therapy in pediatric patients. In this review paper, we discuss some of the current literature on cholesterol-lowering therapy in children, including the statins that are currently available for use in children, and some of the cautions with using these and other cholesterol-lowering medications. A central tenet of this review is that medications are not a substitute for dietary and lifestyle interventions, and that even in children on cholesterol-lowering medications, physicians should take every opportunity to encourage children and their parents to make healthy diet and lifestyle choices.