1.9.2.0 Dys­lipi­demia

Rec­om­men­da­tions

Test­ing

13.33 Ob­tain a fast­ing lipid profile in chil­dren ≥10 years of age soon after the di­ag­no­sis of di­a­betes (after glu­cose con­trol has been es­tab­lished). E

13.34 If LDL choles­terol val­ues are with­in the ac­cept­ed risk level (<100 mg/dL [2.6 mmol/‍L]), a lipid profile re­peat­ed every 3–5 years is rea­son­able. E

Treat­ment

13.35 If lipids are abnor­mal, ini­tial ther­a­py should con­sist of op­ti­miz­ing glu­cose con­trol and med­i­cal nu­tri­tion ther­a­py using a Step 2 Amer­i­can Heart As­so­ci­a­tion diet to de­crease the amount of sat­u­rat­ed fat to 7% of total calo­ries and di­etary choles­terol to 200 mg/‍day, which is safe and does not in­ter­fere with nor­mal growth and de­vel­op­ment. B

13.36 After the age of 10 years, ad­di­tion of a statin is sug­gested in pa­tients who, de­spite med­i­cal nu­tri­tion ther­a­py and lifestyle changes, con­tin­ue to have LDL choles­terol >160 mg/dL (4.1 mmol/‍L) or LDL choles­terol >130 mg/dL (3.4 mmol/‍L) and one or more car­dio­vas­cu­lar dis­ease risk fac­tor, fol­low­ing re­pro­duc­tive coun­sel­ing be­cause of the po­ten­tial ter­ato­genic ef­fects of statins. E

13.37 The goal of ther­a­py is an LDL choles­terol value <100 mg/dL (2.6 mmol/‍L). E

Pop­u­la­tion-‍based stud­ies es­ti­mate that 14–45% of chil­dren with type 1 di­a­betes have two or more atheroscle­rot­ic car­dio­vas­cu­lar dis­ease (ASCVD) risk fac­tors (92-94), and the preva­lence of car­dio­vas­cu­lar dis­ease (CVD) risk fac­tors in­creas­es with age (94) and among racial/‍ eth­nic mi­nori­ties (21), with girls hav­ing a high­er risk bur­den than boys (93).

Patho­phys­i­ology.

The atheroscle­rot­ic pro­cess be­gins in child­hood, and al­though ASCVD events are not ex­pect­ed to occur dur­ing child­hood, ob­ser­va­tions using a va­ri­ety of method­olo­gies show that youth with type 1 di­a­betes may have subclin­i­cal CVD with­in the first decade of di­ag­no­sis (95-97). Stud­ies of carotid in­ti­ma-‍media thick­ness have yield­ed incon­sistent re­sults (90,91).

Treat­ment.

Pe­di­atric lipid guide­lines pro­vide some guid­ance rel­e­vant to chil­dren with type 1 di­a­betes (90,98–100); how­ev­er, there are few stud­ies on mod­i­fy­ing lipid lev­els in chil­dren with type 1 di­a­betes. A 6-‍month trial of di­etary coun­sel­ing pro­duced a significant im­provement in lipid lev­els (101); like­wise, a lifestyle in­ter­ven­tion trial with 6 months of ex­er­cise in ado­les­cents demon­strat­ed im­provement in lipid lev­els (102).

Al­though in­ter­ven­tion data are sparse, the Amer­i­can Heart As­so­ci­a­tion cat­e­go­rizes chil­dren with type 1 di­a­betes in the high­est tier for car­dio­vas­cu­lar risk and rec­om­mends both lifestyle and phar­ma­co­log­ic treat­ment for those with el­e­vat­ed LDL choles­terol lev­els (100,103). Ini­tial ther­a­py should be with a nu­tri­tion plan that re­stricts sat­u­rat­ed fat to 7% of total calo­ries and di­etary choles­terol to 200 mg/‍day. Data from ran­dom­ized clin­i­cal tri­als in chil­dren as young as 7 months of age in­di­cate that this diet is safe and does not in­ter­fere with nor­mal growth and de­vel­op­ment (104).

For chil­dren with a significant fam­i­ly his­to­ry of CVD, the Na­tion­al Heart, Lung, and Blood In­sti­tute rec­om­mends ob­tain­ing a fast­ing lipid panel be­gin­ning at 2 years of age (98). Abnor­mal re­sults from a ran­dom lipid panel should be confirmed with a fast­ing lipid panel. Data from the SEARCH for Di­a­betes in Youth (SEARCH) study show that im­proved glu­cose con­trol over a 2-year pe­ri­od is as­so­ci­at­ed with a more fa­vor­able lipid profile; how­ev­er, im­proved glycemic con­trol alone will not nor­malize lipids in youth with type 1 di­a­betes and dys­lipi­demia (105).

Nei­ther long-‍term safe­ty nor car­dio­vas­cu­lar out­come efficacy of statin ther­a­py has been es­tab­lished for chil­dren; how­ev­er, stud­ies have shown short-‍term safe­ty equiv­a­lent to that seen in adults and efficacy in low­er­ing LDL choles­terol lev­els in fa­mil­ial hypercholes­terolemiaorse­vere hy­per­lipi­demia, im­prov­ing en­dothe­lial func­tion and caus­ing re­gres­sion of carotid in­ti­mal thick­en­ing (106,107). Statins are not ap­proved for pa­tients aged <10 years, and statin treat­ment should gen­er­ally not be used in chil­dren with type 1 di­a­betes be­fore this age. Statins are contrain­di­cated in preg­nan­cy; there­fore, pre­ven­tion of un­planned preg­nan­cies is of paramount im­por­tance for post­pu­ber­tal girls (see Sec­tion 14 “Man­age­ment of Di­a­betes in Preg­nan­cy” for more infor­mation). The mul­ti­cen­ter, ran­dom­ized, placebo-con­trolled Ado­les­cent Type 1 Di­a­betes Cardio-‍Renal In­ter­ven­tion Trial (AdDIT) pro­vides safe­ty data on phar­ma­co­log­ic treat­ment with an ACE in­hibitor and statin in ado­les­cents with type 1 di­a­betes.