IntroductionDr Hannah Farrimond questions whether overweight children should be prescribed statins.
The American Association of Paediatricians (AAP) has suggested that children as young as eight might benefit from taking statins, a drug which lowers cholesterol. Dr Farrimond takes issue with that advice.
What has the AAP recommended and why? The AAP has recommended that children over eight who have a very high cholesterol level, plus risk factors such as obesity, or a family history of cardiovascular disease, should be offered statins. The AAP argues that although we cannot know exactly which children will develop athlerosclerosis (plaque in the arteries), it is better to get those at the highest risk started on statins to prevent heart disease or strokes later in life. It suggests screening all overweight children, those with a family history of heart disease or other risk factors. Those under eight will be offered lifestyle advice; those over eight with very high cholesterol will additionally be offered statins. Those who start statins at this age may have to take them over the long-term, perhaps for life.
Can obese children in the UK get statins? In the UK, only children diagnosed with a genetic disorder linked to high cholesterol and early heart disease (familial hypercholesterolemia) are to be offered statins. The National Institute for Clinical Excellence (NICE) does not recommend widespread statin use among obese children. What are the potential problems with giving children statins? The first problem is that there simply is a lack of evidence about statin use in this age group. Nearly all trials have been carried out with adults. This means that no-one knows how statins may affect children who are still developing. Despite being relatively safe, and available over the counter for adults in the UK, statins also have a well-known side effect profile, including muscle fatigue and, very rarely, liver disease. If large numbers of obese children start taking statins, some will inevitably suffer from the side-effects. Children may be less able to tell doctors about how their body feels, or to know if any side-effects are normal. Some people even debate the importance of cholesterol as the determining factor in coronary heart disease. At best, reducing cholesterol modestly reduces the risk. It is also unclear whether children or their parents might give up on lifestyle changes if offered statins. It has been suggested that offering a ‘pill’ for cholesterol de-incentivises people to make lifestyle changes, such as going on a low cholesterol diet or taking exercise, because their problem is 'being dealt with’ by their tablets. If this happens then the other risk factors, such as obesity, are likely to remain and pose a continuing risk for diabetes and other conditions. On the other hand, it could be argued that it is better to lower the risk by any means than to continue untreated. The ADDFAM (Adding family history to coronary heart disease risk assessments) study at EGENIS has looked at how ‘high risk’ adults perceive and respond to statins and lifestyle choices. More research needs to be done with parents and children at ‘high risk’ of cardio-vascular disease (CVD) to understand whether they would want to consider statins, and if so, whether this may unintentionally create an over-reliance on a pharmaceutical solution. It is also hard to see this as anything but ‘mission-creep’ on the part of the pharmaceutical companies. Recent headlines such as ‘statins for all over 50s’ have shocked both doctors and ordinary people concerned that the pharmaceutical companies are medicalising middle-age. The notion that they are medicalising childhood, offering statins for life from the age of eight upwards, is equally concerning. The risk criteria - obesity, family history of diabetes or CVD and elevated cholesterol - are increasingly common in developed countries. This could lead to large numbers of children and adolescents starting statins at a young age, and at a much lower risk threshold than is currently used for adults. Statins are drugs that have to be taken long-term in most cases. The earlier they are started, the more the treatment will cost over a lifetime. It is unclear that the cost-benefit analysis on the basis of which NICE recommends statins to high-risk adults will hold for those under 50. There is concern that the statin bill could bankrupt the NHS. This is all the more likely if statin use for young overweight children and adults gains widespread acceptance as a clinical norm.