Sometimes guidelines cause people to be on medication who otherwise would not need to be. We have seen this concern due to runaway claims about the nebulous "pre-diabetes" diagnoses being discussed, and in commercials on television for prescription products to prevent anaphylaxis even though 0.05% of kids is ever going to be at risk and they are exploiting the allergy fad culture to make money.
If we want to have 400,000 more young people on statins who don't need them we just need to use pediatric guidelines for lipid levels of 17 to 21 year olds who have elevated low-density lipoprotein cholesterol (LDL-C) levels rather than adult guidelines.
Adolescence is increasingly cited as when risk factors for cardiovascular disease, including abnormal cholesterol levels, emerge, which can be important to recognize but makes young people nihilistic. We saw this in anti-smoking campaigns decades ago, where claims that 'you will get lung cancer if you smoke' ignored that only 10 percent of smokers get lung cancer and 50 percent of lung cancer patients never smoked but also had young people saying 'I might as well keep smoking because I am doomed anyway'.
Statins are controversial so until that is settled we shouldn't be putting young people on them unnecessarily yet the National Heart, Lung, and Blood Institute and the American College of Cardiology and American Heart Association Guideline differ in their recommendations regarding statin use. Because 17 to 21 years is a typical age for transition from pediatric to adult-centered care, these disparate approaches may lead to confusion in clinical practice, according to background information in the article.
Holly C. Gooding, M.D., M.Sc., of Boston Children's Hospital, and colleagues compared the proportion of young people 17 to 21 years of age who meet criteria for pharmacologic treatment of elevated LDL-C levels under pediatric vs adult guidelines. The researchers used data from the National Health and Nutrition Examination Survey (NHANES). Surveys were administered from January 1999 through December 2012, and the analysis was performed from June through December 2014.
Of the 6,338 persons 17 to 21 years of age in the NHANES population included in this analysis, 2.5 percent would qualify for statin treatment under the pediatric guidelines compared with 0.4 percent under the adult guidelines. Extrapolating to the U.S. population of 20.4 million people age 17 to 21 years, 483,500 individuals would be eligible for statin treatment under the pediatric guidelines compared with 78,200 under the adult guidelines, a difference of about 400,000. The authors note that the actual number treated is likely to be much lower owing to less than universal screening in this age group, challenges with adherence to medication regimens, and physician or patient disagreement with the recommendations.
Participants who met pediatric criteria had lower average LDL-C levels (167 vs 210 mg/dL) but higher proportions of other cardiovascular risk factors, including hypertension, smoking, and obesity compared with those who met the adult guidelines.
"Given the current uncertain state of knowledge and conflicting guidelines for treatment of lipid levels among youth aged 17 to 21 years, physicians and patients should engage in shared decision making around the potential benefits, harms, and patient preferences for treatment. The 2013 American College of Cardiology and American Heart Association guidelines recommend shared decision making with patients for whom data are inadequate, including young people with a high lifetime risk for atherosclerotic cardiovascular disease. Patients and clinicians should clearly address other modifiable risk factors, including optimizing diet, exercise, and weight and promoting abstinence from tobacco, as strongly recommended by both the pediatric and adult guidelines," the researchers conclude.
Citation: JAMA Pediatr April 6, 2015 doi:10.1001/jamapediatrics.2015.0168.