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zoom RSS 小児へのコレステロール降下薬投与

<<   作成日時 : 2008/07/09 01:55   >>

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 米国の小児科医が、成人後の心臓疾患を予防するために子どもに対してより広範なコレステロールのスクリーニングと8才からのコレステロール降下剤の使用を推奨した新たなガイドラインが出される。
画像 以前に、6-12ヶ月の体重減少努力に失敗したときには10才以上ならコレステロール降下剤が考慮されるべきだとしていたが、子どもの肥満が増加し30%となり、心臓病の最初の徴候が子どもで現れるという事実が次々に出されており、多くの医師が早期の心臓発作や糖尿病が爆発的に増加すると恐れている。statins が心臓発作のリスクを下げる最善の希望である可能性がある。
 高コレステロール家系か男55才女65才前の心臓発作の家系なら、コレステロールスクリーニングを2才から、遅くても10才までに開始するように求めている。正常値の場合、3-5年後に再検査を提案。190mg以上ならば、8才以上ならコレステロール降下剤を160mgになるまで服用する。糖尿病を持つ子どもは130mg/dl以上で薬物療法を考慮する。
 statinsは1980年代中頃以降の薬剤であり、子どもに投与して、中年以降の心臓発作リスクをさげるだろうか証拠はない。(NYTimes)

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July 7, 2008, 12:15 am
Cholesterol Drugs for Kids
http://well.blogs.nytimes.com/2008/07/07/cholesterol-drugs-for-kids/

The nation’s pediatricians are recommending wider cholesterol screening for children and more aggressive use of cholesterol-lowering drugs starting as early as the age of 8 in hopes of preventing adult heart problems.

The new guidelines were to be issued by the American Academy of Pediatrics on Monday. The push to aggressively screen and medicate for high cholesterol in children is certain to create controversy amid a continuing debate about the use of prescription drugs in children as well as the best approaches to ward off heart disease in adults.

But proponents say there is growing evidence that the first signs of heart disease show up in childhood, and with 30 percent of the nation’s children overweight or obese, many doctors fear that a rash of early heart attacks and diabetes is on the horizon as these children grow up.

Previously, the academy had said cholesterol drugs should be considered in children older than 10 if they fail to lose weight after a 6- to 12-month effort. The academy estimated that under the current guidelines, 30 percent to 60 percent of children with high cholesterol were being missed. And for some children, cholesterol-lowering drugs, called statins, may be their best hope of lowering their risk of early heart attack, proponents said.

“We are in an epidemic,” said Dr. Jatinder Bhatia, a member of the academy’s nutrition committee who is a professor and chief of neonatology at the Medical College of Georgia in Augusta. “The risk of giving statins at a lower age is less than the benefit you’re going to get out of it.”

Dr. Bhatia said that although there was not “a whole lot” of data on pediatric use of cholesterol-lowering drugs, recent research showed that the drugs were generally safe for children.

Surprisingly, the paper published in the medical journal Pediatrics that explains the new guidelines notes that among adolescents, average total cholesterol levels as well as LDL and HDL cholesterol have remained stable, while triglyceride levels have dropped, based on data collected from 1988 to 2000.

It is not clear how many children would be affected by the new guidelines. The recommendations call for cholesterol screening of children and adolescents, starting as early as the age of 2 and no later than the age of 10, if they come from families with a history of high cholesterol or heart attacks before 55 for men and 65 for women.

Screening is also recommended for children when family history is unknown, or if they have other risk factors, like being at or above the 85th percentile for weight, or have diabetes.

If the child’s cholesterol level is normal, retesting is suggested in three to five years. Although lifestyle changes are still recommended as the first course of action, drug treatment should be considered for children 8 years and older who have bad cholesterol of 190 milligrams per deciliter as when cholesterol reaches 160 in children who also have a family history of early heart disease or two additional risk factors, the new recommendations say. Children with diabetes may be considered for drug treatment when cholesterol reaches 130 mg/dL.

The guidelines give no guidance on how long a child should stay on drug treatment. But they do say the first goal should be to lower bad cholesterol levels to less than 160 milligrams or possibly as low as 110 milligrams in children with a strong family history of heart disease or other risk factors like obesity.

Because statins have been around since only the mid-1980s, there is no evidence to show whether giving statins to a child will lower the risk for heart attack in middle age.

The academy also now recommends giving children low-fat milk after 12 months if a doctor is concerned about future weight problems. Although children need fat for brain development, the group says that because children often consume so much fat, low-fat milk is now appropriate.

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Cholesterol Drugs Recommended for Some 8-Year-Olds
Pediatrics academy urges cholesterol drugs for some 8-year-olds to fight heart disease
By LINDSEY TANNER AP Medical Writer
CHICAGO July 7, 2008 (AP)
The Associated Press

For the first time, an influential doctors group is recommending that some children as young as 8 be given cholesterol-fighting drugs to ward off future heart problems.
kids
For the first time ever, a doctors group is recommending that some children as young as 8 take cholesterol-lowering statin drugs.
(Getty/ABC News)

It is the strongest guidance ever given on the issue by the American Academy of Pediatrics, which released its new guidelines Monday. The academy also recommends low-fat milk for 1-year-olds and wider cholesterol testing.

Dr. Stephen Daniels, of the academy's nutrition committee, says the new advice is based on mounting evidence showing that damage leading to heart disease, the nation's leading killer, begins early in life.

It also stems from recent research showing that cholesterol-fighting drugs are generally safe for children, Daniels said.

Several of these drugs are approved for use in children and data show that increasing numbers are using them.

"If we are more aggressive about this in childhood, I think we can have an impact on what happens later in life ... and avoid some of these heart attacks and strokes in adulthood," Daniels said. He has worked as a consultant to Abbott Laboratories and Merck & Co., but not on matters involving their cholesterol drugs.

Drug treatment would generally be targeted for kids at least 8 years old who have too much LDL, the "bad" cholesterol, along with other risky conditions, including obesity and high blood pressure.

For overweight children with too little HDL, the "good" cholesterol, the first course of action should be weight loss, more physical activity and nutritional counseling, the academy says.

Pediatricians should routinely check the cholesterol of children with a family history of inherited cholesterol disease or with parents or grandparents who developed heart disease at an early age, the recommendations say. Screening also is advised for kids whose family history isn't known and those who are overweight, obese or have other heart disease risk factors.

Screening is recommended sometime after age 2 but no later than age 10, at routine checkups.

The academy's earlier advice said cholesterol drugs should only be considered in children older than 10 after they fail to lose weight. Its previous cholesterol screening recommendations also were less specific and did not include targeted ages for beginning testing.

Because obesity is a risk factor for heart disease and often is accompanied by cholesterol problems, the academy recommendations say low-fat milk is appropriate for 1-year-olds "for whom overweight or obesity is a concern."
Daniels, a pediatrician in the Denver area, agreed that could include virtually all children. But he said doctors may choose to offer the new milk advice only to 1-year-olds who are already overweight or have a family history of heart problems.

The academy has long recommended against reduced-fat milk for children up to age 2 because saturated fats are needed for brain development.

"But now we have the obesity epidemic and people are thinking maybe this isn't such a good idea," said Dr. Frank Greer of the University of Wisconsin, co-author of the guidelines report, which appears in the July edition of Pediatrics, the group's medical journal.

Very young children are increasingly getting fats from sources other than milk and Greer said the updated advice is based on recent research showing no harm from reduced-fat milk in these youngsters.

With one-third of U.S. children overweight and about 17 percent obese, the new recommendations are important, said Dr. Jennifer Li, a Duke University children's heart specialist.

"We need to do something to stem the tide of childhood obesity," Li said.

Li said that 15 years ago most of her patients with cholesterol problems had an inherited form of cholesterol disease not connected to obesity.

"But now they're really outnumbered" by overweight kids with cholesterol problems and high blood pressure, she said.

Dr. Elena Fuentes-Afflick, a pediatrics professor at the University of California at San Francisco, also praised the new advice but said some parents think their kids will outgrow obesity and cholesterol problems, and might not take it seriously.

"It's hard for people to really understand" that those problems in childhood can lead to serious health consequences in adulthood, Fuentes-Afflick said.

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On the Net:
American Academy of Pediatrics: http://www.aap.org/

Copyright 2008 The Associated Press. All rights reserved. This material may not be published, broadcast, rewritten, or redistributed.

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Published online July 1, 2008
PEDIATRICS Vol. 122 No. 1 July 2008, pp. 198-208 (doi:10.1542/peds.2008-1349)
CLINICAL REPORT
Lipid Screening and Cardiovascular Health in Childhood
Stephen R. Daniels, MD, PhD, Frank R. Greer, MD and the Committee on Nutrition
http://pediatrics.aappublications.org/cgi/content/abstract/122/1/198

This clinical report replaces the 1998 policy statement from the American Academy of Pediatrics on cholesterol in childhood, which has been retired. This report has taken on new urgency given the current epidemic of childhood obesity with the subsequent increasing risk of type 2 diabetes mellitus, hypertension, and cardiovascular disease in older children and adults. The approach to screening children and adolescents with a fasting lipid profile remains a targeted approach. Overweight children belong to a special risk category of children and are in need of cholesterol screening regardless of family history or other risk factors. This report reemphasizes the need for prevention of cardiovascular disease by following Dietary Guidelines for Americans and increasing physical activity and also includes a review of the pharmacologic agents and indications for treating dyslipidemia in children.

Key Words: lipid screening . children . cardiovascular disease . cholesterol . lipid profile . dyslipidemia . obesity . familial hypercholesterolemia . statins

Abbreviations: CVD―cardiovascular disease . AAP―American Academy of Pediatrics . LDL―low-density lipoprotein . HDL―high-density lipoprotein . PDAY―Pathobiological Determinants of Atherosclerosis in Youth . IMT―intimal medial thickness . NHANES―National Health and Nutrition Examination Survey . NCEP―National Cholesterol Education Program . VLDL―very low-density lipoprotein

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