From the Guidelines
Hypercholesterolemia in adolescents should be treated with a stepwise approach, starting with lifestyle modifications before considering medication, as recommended by the 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol 1.
Stepwise Approach to Treatment
The treatment approach should begin with dietary changes, including reduced saturated fat and increased fiber intake, regular physical activity of at least 60 minutes daily, and weight management if needed. These interventions should be maintained for 6-12 months before considering pharmacotherapy.
Consideration for Pharmacotherapy
If lifestyle changes are insufficient and the adolescent has significant risk factors, such as a family history of premature cardiovascular disease, LDL-C ≥190 mg/dL, or multiple cardiovascular risk factors, medication may be warranted. Statins are the first-line medication, typically starting with lower doses such as atorvastatin 10 mg or rosuvastatin 5 mg daily, with gradual titration if needed 1.
Additional Considerations
Other medications like ezetimibe (10 mg daily) may be added for those who cannot tolerate statins or need additional LDL lowering. Treatment decisions should be individualized based on the severity of hypercholesterolemia, family history, and presence of other risk factors. Regular monitoring of lipid levels (every 3-6 months initially), liver function tests, and assessment for muscle symptoms is essential.
Justification for Treatment
Treatment is justified because early intervention can prevent atherosclerotic changes that begin in youth and progress to cardiovascular disease in adulthood, as supported by the American Heart Association guidelines 1.
Key Recommendations
- Lifestyle modifications should be the initial approach to treating hypercholesterolemia in adolescents.
- Pharmacotherapy, starting with statins, should be considered if lifestyle changes are insufficient and the adolescent has significant risk factors.
- Treatment decisions should be individualized based on the severity of hypercholesterolemia, family history, and presence of other risk factors.
- Regular monitoring of lipid levels, liver function tests, and assessment for muscle symptoms is essential.
From the FDA Drug Label
The effects of ezetimibe tablet coadministered with simvastatin (n=126) compared to simvastatin monotherapy (n=122) have been evaluated in males and females with HeFH. In a multicenter, double-blind, controlled trial followed by an open-label phase, 142 males and 106 postmenarchal females, 10 to 17 years of age (mean age 14. 2 years, 43% females, 82% White, 4% Asian, 2% Black or African American, 13% multi- racial; 14% identified as Hispanic or Latino ethnicity) with HeFH were randomized to receive either ezetimibe tablet coadministered with simvastatin or simvastatin monotherapy
HeFH in Pediatric Patients In a double-blind, placebo-controlled trial followed by an open-label phase, 187 males and post-menarchal females 10 years to 17 years of age (mean age 14.1 years; 31% female; 92% White, 1.6% Black or African American, 1.6% Asian, 4. 8% other) with heterozygous familial hypercholesterolemia (HeFH) or severe hypercholesterolemia, were randomized to atorvastatin calcium (n=140) or placebo (n=47) for 26 weeks and then all received atorvastatin calcium for 26 weeks
Hypercholesterolemia treatment in adolescents:
- Yes, hypercholesterolemia should be treated in adolescents, specifically those with heterozygous familial hypercholesterolemia (HeFH) or severe hypercholesterolemia, as evidenced by the clinical trials evaluating the efficacy of ezetimibe and atorvastatin in this population 2 3.
- The treatment goals and approaches may vary depending on the individual patient's risk factors, family history, and clinical presentation.
- Key considerations include:
- The use of statins, such as atorvastatin, as a first-line treatment for HeFH or severe hypercholesterolemia in adolescents.
- The potential benefits of combination therapy with ezetimibe and simvastatin in achieving greater reductions in LDL-C levels.
- The importance of monitoring and managing potential side effects, such as myopathy and liver enzyme elevations, associated with statin therapy.
From the Research
Treatment of Hypercholesterolemia in Adolescents
The treatment of hypercholesterolemia in adolescents is a crucial aspect of preventing cardiovascular disease later in life. According to 4, severe hyperlipidemias should be diagnosed and treated even in childhood and adolescence, as vascular lipid deposition can start to develop early in life.
Diagnosis and Treatment
The diagnosis of hypercholesterolemia in adolescents involves identifying genetic dyslipidemias associated with premature cardiovascular disease 5. Treatment guidelines are available from the National Cholesterol Education Program, which recommends a heart-healthy diet starting at the age of 2 years 5.
Dietary Modification
Dietary modification is the basis of treatment for affected children and can lower LDL cholesterol by about 15-20% 4. The reduction of saturated fats and trans fatty acids and their replacement by polyunsaturated and monounsaturated fats is essential for effective dietary treatment 4.
Pharmacotherapy
Pharmacotherapy should be considered in children over 10 years of age when LDL cholesterol concentrations remain very high despite severe dietary therapy, especially when multiple risk factors are present 5. The drugs of first choice are resins, which are reported to be effective and well-tolerated 4, 5. Statins are also increasingly used and seem to be effective and safe in children, although studies have enrolled a small number of patients and evaluated efficacy and safety for short-term periods 5, 6.
Benefits of Early Treatment
Early treatment of hypercholesterolemia in adolescents can help prevent cardiovascular disease later in life 7, 6, 8. Identifying and treating children and adolescents at risk for hypercholesterolemia should lead to a decrease in adult atherosclerotic disease 8.
Key Considerations
Key considerations in the treatment of hypercholesterolemia in adolescents include:
- Dietary modification as the basis of treatment
- Pharmacotherapy in children over 10 years of age with high LDL cholesterol concentrations
- The use of resins and statins as first-line treatments
- The need for long-term follow-up studies to determine the safety and efficacy of early treatment 6
- The importance of identifying and treating children and adolescents at risk for hypercholesterolemia to prevent cardiovascular disease later in life 4, 5, 7, 6, 8