Dyslipidemia in Youth with Diabetes: To Treat or Not to Treat?

Abstract

There are an estimated 1.5 million people with type 1 diabetes (T1D) and 20 million with type 2 diabetes (T2D) in the U.S. today including at least 150 000 younger than 20 years(1). Of concern, both T1D and T2D are increasing in youth and presenting at younger ages(2-4), implying a longer burden of disease and earlier onset of vascular complications(5). Cardiovascular disease (CVD) is the leading cause of death in people with both T1D(6) and T2D(7) and the antecedents of adult CVD are present in children(8-10). Several studies demonstrate tracking of childhood CVD risk factors into adulthood(9-15). Furthermore, CVD risk factors in childhood correlate with abnormalities in surrogate markers of atherosclerosis (such as carotid intima thickness and arterial elasticity)(14;15) and atherosclerotic lesions in pathology evaluations(9;13). Although data indicate that progress has been made reducing microvascular complications in T1D(16;17) and that intensive management with lower HbA1c can reduce CVD events(18), evidence from the Pittsburgh Epidemiology of Diabetes Complications Study suggests a lack of similar progress in reduction of macrovascular as compared with microvascular complications(16). Furthermore, people with both T1D and T2D suffer macrovascular complications and death at earlier ages than non-diabetics(7;19). Importantly, dyslipidemia is a significant CVD risk factor in persons with diabetes(7;20-22) and target low-density lipoprotein cholesterol (LDL) levels continue to be lowered in adults with diabetes (DM)(7). Observational data have emerged recently on prevalence of dyslipidemia in youth with DM(23-26). Yet, despite recent American Diabetes Association (ADA) and American Heart Association (AHA) clinical recommendations on treatment of dyslipidemia in youth with DM(27-30), no treatment data exist in dyslipidemic youth with DM on which to base clinical care. Instead current pediatric recommendations are generated by consensus expert opinion or are extrapolated either from adult data or treatment data on youth with familial hypercholesterolemia(27-31). Given that dyslipidemia is an important and potentially modifiable CVD risk factor, data to inform clinical decision making regarding screening criteria and treatment of dyslipidemia in this high-risk population are of significant public health importance(32). Data from clinical trials in youth with DM are needed to determine the appropriate management strategy. In this article, recent data and current recommendations on dyslipidemia in youth with DM will be reviewed. Evidence supporting the treatment of dyslipidemia in youth with DM will be discussed as well as current treatment options and recommended monitoring. Finally, the question of whether lipid abnormalities in youth with DM should be treated will be addressed.