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Should statins be given to young adults?

Signs of atherosclerosis can start when a person is a teenager, and recent findings in genetics have given more credence to the idea of giving young adults statins.

The effectiveness and safety of the statins, their low cost, and their ubiquity make them appealing as a preventative medication, and the thought is that heart problems can be headed off early if people start taking statins in their 20s or 30s. The problem is that atherosclerotic damage is cumulative. When these people get into their 70s they will be glad they took steps to slow plaque build-up.

The ongoing debate on whether statins are overprescribed intersects with this idea. If even 45-year-olds with no cardiovascular problems should not be given statins (as some doubters advocate), it sounds dumb to give the medication to 25-year-olds. (An exception has long been made for young adults with familial hypercholesterolemia.)

The lipid-lowering effects of statins probably won’t provide short-term benefits to young adults (pleiotropic effects are another question), but the lifetime health payoffs may tilt the cost/benefit calculation in giving the medicine to young adults. Indeed, under the current guidelines, many people as young as 18 should be taking statins regularly. Doctors typically ignore these guidelines for very young adults; whether they should ignore them is another question.

Treating young adults with statins is an example of long-term patient care and preventative medicine that thinkers in public health have been trying to promote. In this case the benefits of the drug might not show up until 40 or more years after ingestion. Cardiovascular disease and related health issues are a major portion of society's overall spending on medicine. Cost benefit analyses are always only as good as their imperfect assumptions and what the analyzers know. The farther out in time the analysis considers costs and benefits, the less likely it is to be accurate.

An On-Going Debate

The science is not conclusive. A study at the University of California at San Francisco found even moderate elevation of cholesterol levels in individuals in their 20s and 30s can predict future problems. The scientists observed people with high levels of LDL cholesterol or lower levels of HDL cholesterol during young adulthood were more likely to develop coronary calcium.- a marker for blood vessel plaques – in middle age. The lead author of this study concluded it is worth considering statin usage for young adults.

One big unknown is how much a reduction in LDL affects long-term risk, and whether statin-induced low levels are as good as naturally low LDL (induced by genes).

Even reflecting on very good results showing atorvastatin therapy reduces all-cause mortality (including from infection and respiratory illness), a doctor who participated in the study said he was said he was not yet ready to recommend statins for people in their 20s.

A Dutch cost/benefit analysis likewise concluded low risk young people should not be given statins when the disappointingly low adherence to the drug was taken into account.

On the "let's expand usage" team are the authors of a study of low risk people past age 45 without high cholesterol or evidence of cardiovascular disease. With low doses of lovastatin, risk factors were even further reduced, causing the authors to suggest that a diagnostic heuristic for initiating a statin regimen could be lowered to "age plus one other risk factor". Some medical writers object, and stress the need for non-pharmacological means of addressing cholesterol problems, and more importantly, CVD risk. They say doctors should forgo statin therapy and impress on young people with high cholesterol the need for getting regular exercise and a healthy diet.

Statin Use in Teens

Noting that “Clinical events such as myocardial infarction, stroke, peripheral arterial disease, and ruptured aortic aneurysm are the culmination of the lifelong vascular process of atherosclerosis” a government expert panel in 2011 recommended education and interventions in children and teens to cut off problems before they happen. Although the focus was mostly on lifestyle and diet, the panel’s report left open the possibility of statin usage, if the doctor feels it is the best course of action. Target cholesterol levels are a lot lower in kids than in adults. The acceptable level in kids to age 19 is under 170 mg/dl. A level of 200 mg/dl is considered high and kids with those levels are candidates for statins.

The panel recommended a screening at about age 10 (lower for children with diabetes) and another at age 18 or so.

An article in JAMA Pediatrics looked at the number of people in the 17-21 year old range who qualify for statin treatment under those criteria (the 2011 panel on juvenile use) and compared it to the number who would qualify under the American College of Cardiology and American Heart Association adult criteria. They concluded that the juvenile criteria, if applied, could result in over five times as many people in that age range being given statins. The writers used this comparison to discount the juvenile criteria.

Personalized treatment

New technology has given birth to a movement in medicine to provide more personalized treatment, perhaps based on the person’s genome. If this philosophy takes over, we may see increased use of statins in young adults, for whom there is a reasonable prediction of future cardiovascular problems.

NPR reported on a company called Boston Heart Diagnostics which offers a test for the SLCO1B1 gene. Scientists have found that this gene may be associated with myopathy. (If this sounds like we are hedging the facts here it’s because the experts aren’t really sure that this gene causes or predict muscle problems with statin use.)

Other genomic markers, KIF6 and SLCO1B1, may inform the therapy choice of patients initiating statins. Research continues in this area.

See also

Statins for children
Statins for seniors

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