Current Issues
Francine R Kaufman, MD
Samuel S Gidding, MD
Catherine J McNeal, MD, PHD
Reviewed by Joelle Escoffery, PhD
There are well-established guidelines for the treatment of dyslipidemia among adult patients with diabetes, and those guidelines are based on a large body of evidence. In 2002, The American Diabetes Association convened a consensus panel to create guidelines for the treatment of dyslipidemia among children with diabetes. Although there was no experimental evidence to drive these guidelines, the panel recommended that lifestyle treatment should be initiated at LDL levels between 100 and 120 mg/dL. At levels between 120 and 159, pharmacologic therapy should be considered, and the presence of other risk factors should be examined to help make this determination. Finally, pharmacologic therapy is recommended at LDL levels of 160 mg/dL and higher.
In terms of early and aggressive treatment for dyslipidemia among children with type 2 diabetes, a number of important points were made. First, diabetes is a vascular disease, and vascular age and chronological age are not equivalent in people with diabetes, as diabetes ages the vascular system much more rapidly. Further, risk factors such as smoking, high blood pressure, obesity, physical inactivity, and diabetes reliably predict risk, and statin therapy reduces risk. The counterargument for early and aggressive treatment focused on the lack of empirical support. The pediatric guidelines from the National Cholesterol Education Program (NCEP) are based primarily on adult data, and they are not adjusted for race and ethnicity. Further, the limited pediatric data available are based on children with familial hypercholesterolemia, who represent only a small portion of the population. Although there have been clinical trials examining statin use in children, many were not powered for safety and did not include surrogate markers of disease such as intima media thickness, flow-mediated dilatation, and C-reactive protein. In summary, there is evidence to support earlier and more aggressive treatment of dyslipidemia in children with type 2 diabetes, but more empirical evidence addressing the most effective way to provide that treatment is needed.
