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Dear Dr. Lanny:
High cholesterol and heart disease run in my family. My father died of a heart attack at age 52. I’m 37 and taking statins on doctor’s orders. What is your opinion of cholesterol-lowering drugs for kids? My son is 10—and active and healthy. I’d like him to stay that way.
Having been in practice for 30 years I have learned many things. Some of them are scientific, but many are not. Foremost among the non-scientific lessons has been that whenever you think an issue has been resolved, that you know what you’re talking about, that’s when the experts will start to contradict what they have been saying with absolute certainty, for years or decades.
Given this uncertainty, it is very difficult to readily sign on to the concept of years’ or possibly lifelong use of cholesterol-lowering drugs, beginning in childhood.
Clearly, elevated cholesterol and heart disease is a major cause of death and disability in our society. Equally clear is the relationship between obesity and both these problems, as well as diabetes and high blood pressure. Despite staggering amounts of time, money and late-night miracle products for only $19.95, we, as a country, have been unable to come anywhere near controlling obesity. Although preventing obesity is theoretically very simple—eat real food, eat less of it and get more activity—actually following that program is remarkably difficult.
If we are unable to control our weight and our cholesterol by controlling our habits, is it not reasonable to turn to medication? Although there are a number of different types of medications to help lower cholesterol, including niacin and cholesterol-binding drugs, nothing has shown as much lowering effect as the statins, a group of drugs that inhibit synthesis of cholesterol, as well as help clear it out of the blood.
The statins were first investigated in the early 1970s, but it was not until 1987 that lovastatin became the first to reach the market. Lipitor (atorvastatin), the giant among the statins, is now the world’s biggest selling drug. Use of this class of drugs has a maximum of a 20-year history, essentially all in adults. Atorvastatin is remarkably effective, dropping cholesterol values by as much as 50 percent. It is well tested, and to this point in its history, quite safe.
As with all medications, significant side effects are possible. What is not clear is whether there could be more significant or different side effects in children. Many drugs, atorvastatin included, have not been studied in children, and it is crucial to understand that children are not just small adults, and may respond to medications very differently than adults do. It is also unclear whether medication in childhood may have untoward effects decades later. Although it seems logical that keeping cholesterol low in childhood decreases heart disease in adult years, that logic has yet to be proven.
Does this mean that cholesterol drugs have no place in children? At this time, these powerful and remarkable medicines probably only have a place in children whose family history has included heart attacks in men younger than 55 years old and women younger than 65 years, and only if the child’s lipid profile (LDL, HDL and cholesterol) is grossly abnormal. In addition the child and family should first have undergone nutrition and lifestyle counseling with repeat blood tests in six to 12 months.
There can be no question that before going to medication, low-tech intervention—meaning decreasing fat in the diet, limiting portion sizes and increasing exercise—is beneficial to our health and also beneficial to the stability of our environment.
I am not anti-statins and have been taking atorvastatin since I had a heart attack while seeing patients a little over two years ago. My lipid profile, which was not awful before my heart attack, is now great. Will good lipids, a healthy diet, and a lot of bicycle riding—always with my helmet—overcome less than perfect genes? I don’t know, but let me tell you that Lance Armstrong keeps an eye out behind him for me.
Dr. Alan Freshman, father of two grown boys, practices at Syracuse Pediatrics. Consult your own physician before making decisions about your family’s health care. Send e-mail to him at firstname.lastname@example.org.