Insufficient evidence for lipid disorder screening in under 20s
medwireNews: There is insufficient evidence to assess the balance of benefits and harms of screening for lipid disorders in children and adolescents, concludes a recommendation statement from the US Preventive Services Task Force (USPSTF).
The report, published in JAMA has been graded an “I statement”, indicating that “[e]vidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.”
To update its 2007 recommendation on screening for lipid disorders in children, adolescents and young adults, the USPSTF commissioned two systematic evidence reviews of data from individuals aged 20 years or younger.
One review focused on screening for heterozygous familial hypercholesterolaemia (FH), while the other focused on screening for multifactorial dyslipidaemia, defined as elevated levels of low-density lipoprotein cholesterol (LDL-C), total cholesterol (TC) or both that are not attributable to FH.
The first review, conducted by Paula Lozano (Group Health Research Institute, Seattle, Washington, USA) and colleagues found that universal screening can detect FH in children, at a diagnostic yield of 1.3 to 4.8 cases per 1000 screened, but there was no adequate evidence on the benefits or harms of FH screening in childhood.
There was adequate evidence to show that lipid-lowering treatment in children with FH can reduce serum lipid concentrations by up to 54% in the short term. But there was no evidence for the effect of screening for FH in childhood on lipid concentrations or cardiovascular outcomes in adulthood, or on the long-term benefits or harms of beginning lipid-lowering treatment in childhood.
Lozano and team also reviewed the data for multifactorial dyslipidaemia, which did not reveal any direct evidence for the benefits or harms of childhood screening or treatment on cardiovascular outcomes in adulthood. Furthermore, the diagnostic yield of lipid screening varied by age and body mass index.
One good-quality, randomised, controlled trial showed that intensive dietary interventions may be safe for the treatment of multifactorial dyslipidaemia, but the benefit was modest, short-lived and “of uncertain clinical significance”, the authors remark. Furthermore, the evidence for the benefits of other lifestyle modifications was inadequate.
Based on the findings of these two reviews, the USPSTF comments: “Evidence on the quantitative difference in diagnostic yield between universal and selective screening approaches, the effectiveness and harms of long-term treatment and the harms of screening, and the association between changes in intermediate outcomes and improvements in adult cardiovascular health outcomes are limited.
“Therefore, the USPSTF concludes that the balance of benefits and harms cannot be determined.”
They acknowledge, however, that “clinical decisions involve more considerations than evidence alone”, and clinicians should therefore “understand the evidence but individualize decision making to the specific patient or situation.”
By Laura Cowen
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