Despite recent advances in diabetes care and modest improvements in glycemic control, Type 1 diabetes (T1D) remains a major risk factor for early onset vascular disease, and is associated with a tenfold increase in cardiovascular related and all-cause mortality compared to the general population. Evidence of vascular endothelial dysfunction and early subclinical atherosclerotic disease can be detected during childhood, and is significantly more prevalent in children and adolescents with T1D in whom vascular changes appear to being soon after diagnosis and accelerate during puberty. The pathogenesis of these vascular abnormalities can in part be attributed to the underlying dyslipidaemia that occurs in T1D. Early management and treatment of abnormal lipid levels is advocated and should not be delayed given that optimised glycaemic control alone is unlikely to normalise lipid profiles. Treatment with oral HMG-CoA reductase inhibitors (i.e. statin agents) has been shown to be highly efficacious and safe at reducing LDL cholesterol (LDL-C) levels and at decreasing the risk of first cardiovascular disease events, including stroke and myocardial infarction, in adult patients with or without diabetes; irrespective of severity of the initial lipid profile. Statins may have effects other than the reduction in cholesterol levels, including inhibition of arterial smooth muscle cell proliferation, prevention of oxidation of LDL-C, plaque stabilisation, effects on macrophages, improvement of endothelial dysfunction, as well as anti-inflammatory and anti-thrombotic effects. Currently, experience of using statins in children has been limited to those with disorders of lipid metabolism such as familial hypercholestrolaemia, where the safety profile of treatment with these drugs has been excellent. There thus appears to be sound rationale for using statin agents in young people with T1D, particularly in those patients with risk factors or signs of early (micro)vascular disease, however the clinical benefits and long-term cost-effectiveness of treatment in this setting are yet to be determined. Ongoing clinical trials and future longitudinal studies should hopefully address these outstanding issues and are eagerly awaited.
23 - 25 Nov 2016
British Society for Paediatric Endocrinology and Diabetes