Andersons pediatric cardiology 654
Bạn đang xem bản rút gọn của tài liệu. Xem và tải ngay bản đầy đủ của tài liệu tại đây (162.05 KB, 3 trang )
qualifyforintensificationoftreatmentatalowerLDL-Clevel.Cholesterolbindingresinsmayalsobeusedalthoughadherenceispoorduetolackof
palatability(grainypowders)orlargepillsrequiringmultipledosesinaday.162
Amodifiedversionoftheproposedtreatmentalgorithmforthetreatmentof
elevatedLDL-C,adaptedfromtheExpertPanelGuidelines,isshowninFig.
25.6.Ofnote,toconfirmelevatedfastinglipidlevels,twomeasurementsshould
betakenmorethan2weeksapartbutnomorethan3monthsapart.Statin
therapyshouldnotbeinitiateduntila6-monthtrialoflifestylemanagementhas
beenundertaken,assummarizedabove.Initiationthresholdsvarybasedonthe
presenceofmoderate-andhigh-levelriskfactors(Box25.1).Whilechildren
youngerthan10yearsoldshouldnottypicallybetreated,considerationmaybe
madeiftheyhaveasevereprimaryhyperlipidemia(e.g.,homozygousFHwith
LDL-C≥400mg/dL),averyhigh-riskfamilyhistory,high-riskconditions,or
multipleriskfactors.23ChildrenwithLDL-Clevelsof250mg/dLorhigheror
TGof500mg/dLorhighershouldbereferreddirectlytoalipidspecialist.Statin
therapyshouldbegivenoncedaily,atthelowestavailabledose.Currently,
choiceofstatinsisamatterofpreference.Atypicalinitialregimenmayinclude
5to10mgofatorvastatinoncedailyunlessthefamily/patientprefersadifferent
medication(e.g.,ifone/bothoftheparentsaretakingadifferentstatin).
FIG.25.6 Low-densitylipoproteincholesterol(LDL-C)treatment
algorithm.aUseofdrugtherapyistypicallylimitedtochildren>10years
withdefinedriskprofiles.bLifestylemodificationsincludemaintaining25%
to30%ofdailycaloriesfromfatwith<7%fromsaturatedfat,about10%
frommonosaturatedfat,and<200mg/dayofcholesterolwithanavoidance
oftransfatsasmuchaspossible.Supportiveactionsincludeadditionof
plantsterolestersand/orplantstanolesters,water-solublefiberpsyllium,
andphysicalactivity.cInachildwithLDL>190mg/dLandotherriskfactors,
lifestyleinterventionsmaybeabbreviated.FHx,Familyhistory;FLP,fasting
lipidprofile;HDL-C,high-densitylipoproteincholesterol.(Modifiedfrom
ExpertPanelonIntegratedGuidelinesforCardiovascularHealthandRisk
ReductioninChildrenandAdolescents;NationalHeart,Lung,andBlood
Institute.Expertpanelonintegratedguidelinesforcardiovascularhealth
andriskreductioninchildrenandadolescents:summaryreport.Pediatrics.
2011;128[suppl5]:S213–S256.)
Box25.1
RiskFactorDefinitionsforDyslipidemia
Algorithms
Positivefamilyhistory:myocardialinfarction,angina,orcoronaryartery
bypassgraft/stent/angioplasty,suddencardiacdeathinparent,grandparent,aunt,
oruncle,male<55yearsold,female<65yearsold.
High-levelriskfactors:
▪Hypertensionrequiringdrugtherapy(BP≥99thpercentile+5mmHg)
▪Currentcigarettesmoker
▪BMI≥97thpercentile
▪Presenceofhigh-riskconditions(seeTable25.4)
Moderate-levelriskfactors:
▪Hypertensionnotrequiringdrugtherapy
▪BMI≥95thpercentilebut<97thpercentile
▪HDL-C<40mg/dL
▪Presenceofmoderate-riskconditions(seeTable25.4)
BMI,Bodymassindex;HDL-C,high-densitylipoprotein-cholesterol.
ModifiedfromExpertPanelonIntegratedGuidelinesforCardiovascularHealth
andRiskReductioninChildrenandAdolescents;NationalHeart,Lung,and
BloodInstitute.Expertpanelonintegratedguidelinesforcardiovascularhealth
andriskreductioninchildrenandadolescents:summaryreport.Pediatrics.
2011;128(suppl5):S213–S256.
Priortoinitiatingstatintherapy,theclinicianshouldinquireaboutpotentially
interactivemedicationssuchascyclosporine,niacin,fibricacidderivatives,
erythromycin,azoleantifungalagents,nefazodone,andmanyHIVprotease
inhibitors.23Patientsshouldseekcounselfromtheirphysicianpriortoinitiating
newmedications.Inaddition,abaselinehepaticpanelandcreatinekinase(CK)
shouldbetaken.Patientsshouldbeinstructedtoreportallpotentialadverse
effects,especiallymusclecramps,weakness,asthenia,andanyotherdiffuse
symptomssuggestiveofmyopathy.Ifthereareconcernsforpotentialmyopathy,
thestatinshouldbestoppedandCKmeasuredimmediately.Ahistoryofrecent
physicalactivityshouldbetaken.ACKlevelgreaterthan10timestheupper
limitofnormalshouldpromptmonitoringforresolutionofmyopathysymptoms
andrepeatCKlevels.Themedicationmaypotentiallyberestartedonce
