TABLE 9-9

Evidence-Based Recommendations for Pharmacologic Treatment of Dyslipidemia

Birth to 10 yPharmacologic treatment is limited to children with severe primary hyperlipidemia (homozygous familial hypercholesterolemia, primary hypertriglyceridemia [triglycerides ≥ 500 mg/dL]), a high-risk condition (Tables 9-6 and 9-7), or evident cardiovascular disease, all under the care of a lipid specialistGrade C Recommend
≥10 to 21 yDetailed family history and RF assessment required before initiation of drug therapya (high- to moderate-level RFs and RCs are listed in Tables 9-6 and 9-7)Grade C Strongly recommend
    LDL cholesterol
        If average LDL cholesterol ≥ 250 mg/dLa, consult lipid specialistGrade B Strongly recommend
        If average LDL cholesterol ≥ 130–250 mg/dL, or non-HDL ≥ 145 mg/dL:
            Refer to dietitian for medical nutrition therapy with CHILD-1 → CHILD-2–LDL (Table 9-8) for 6 mo; repeat FLPGrade A Strongly recommend
    Repeat FLP
        LDL cholesterol < 130 mg/dL, continue CHILD-2–LDL, reevaluate in 12 moGrade A Strongly recommend
        LDL cholesterol ≥ 190 mg/dL,b consider initiation of statin therapy per Tables 9-11 and 9-12Grade A Strongly recommend
        LDL cholesterol ≥ 130–189 mg/dL, negative family history, no other RF or RC, continue CHILD-2–LDL, reevaluate every 6 moGrade B Recommend
        LDL cholesterol = 160–189 mg/dL + positive family history or ≥1 high-level RF/RC or ≥2 moderate-level RFs/RCs, consider statin therapy per Tables 9-11 and 9-12Grade B Recommend
        LDL cholesterol ≥ 130–159 mg/dL + ≥2 high-level RFs/RCs or 1 high-level + 2 moderate-level RFs/RCs, consider statin therapy per Tables 9-11 and 9-12Grade B Recommend
        Children on statin therapy should be counseled and carefully monitored per Table 9-12Grade A Strongly recommend
≥10 to 21 yDetailed family history and RF/RC assessment required before initiation of drug therapya (high- and moderate-level RFs/RCs in Tables 9-6 and 9-7c)Grade C Strongly recommend
    Triglycerides
        If average triglycerides ≥ 500 mg/dL, consult lipid specialistGrade B Recommend
        If average triglycerides ≥ 100 mg/dL in a child aged <10 y, ≥130 mg/dL in a child aged 10–19 y, or <500 mg/dL:
            Refer to dietitian for medical nutrition therapy with CHILD-1 → CHILD-2–TG (Table 9-8) for 6 moGrade B Strongly recommend
        Repeat FLP
            Triglycerides < 100 (130) mg/dL, continue CHILD-2–TG, monitor every 6–12 moGrade B Strongly recommend
            Triglycerides > 100 (130) mg/dL, reconsult dietitian for intensified CHILD-2–TG diet counselingGrade C Recommend
            Triglycerides ≥ 200–499 mg/dL, non-HDL ≥ 145 mg/dL, consider fish oil ± consult lipid specialistGrade D Recommend
    Non-HDL cholesterol
        Children aged ≥10 y with non-HDL cholesterol ≥ 145 mg/dL after LDL cholesterol goal is achieved may be considered for additional treatment with statins, fibrates, or niacin in conjunction with a lipid specialist consultationGrade D Optional
  • Grades reflect the findings of the evidence review, and recommendation levels reflect the consensus opinion of the expert panel. When medication is recommended, it should always be in the context of the complete cardiovascular risk profile of the patient and in consultation with the patient and the family. Values given are in mg/dL. To convert to SI units, divide the results for TC, LDL cholesterol, HDL cholesterol, and non-HDL cholesterol by 38.6; for triglycerides, divide by 88.6. RF indicates risk factor; RC, risk condition.

  • a Consideration of drug therapy is based on the average of ≥2 FLPs, obtained at least 2 weeks but no more than 3 months apart.

  • b If average LDL cholesterol ≥ 190 mg/dL after CHILD-2–LDL and child is 8 to 9 years old with a positive family history or ≥1 high-level risk factor/risk condition or ≥2 moderate-level risk factors/risk conditions, statin therapy may be considered.

  • c If the child is obese, nutrition therapy should include calorie restriction and increased activity beyond that recommended for all children. See “Overweight and Obesity” for additional age-specific recommendations.