Dr Farrah Rodrigues

There are calls to simplify lipid screening guidelines for young patients with type 1 diabetes, after a Melbourne study revealed wide gaps between international recommendations and everyday clinical practice.

Researchers at the Royal Children’s Hospital tracked 335 patients with type 1 diabetes, examining how closely lipid screening followed international guidelines and what happened after abnormal results.

They noted International Society for Paediatric and Adolescent Diabetes (ISPAD) guidelines recommend lipid screening from age 11, repeated every three years. But the guidelines left gaps, given they did not specify how often to retest abnormal LDL-C, or exactly when to start pharmacotherapy, according to the team.

Their analysis found:

• 78% of patients had initial screening in line with guidelines, but repeat testing occurred far more often than recommended, at a mean of every 17 months
• 55% of patients had at least one abnormal lipid result
• One quarter had abnormal LDL-C, yet only one of these patients was referred to a dietitian, and none started statin therapy

Paediatric endocrinologist Dr Farrah Rodrigues, a PhD student at Murdoch Children’s Research Institute, and colleagues wrote in Diabetic Medicine [link here] that screening recommendations for T1D-related vascular complications were “confusing and challenging to recall and practically implement”.

The authors suggested the more-frequent-than-recommended testing likely occurred because lipid checks were bundled with other routine complication screening, rather than being ordered as a standalone test.

Guidance on LDL-C targets and statin thresholds has also shifted over time, the authors noted. The 2022 ISPAD guidelines recommend starting statins if LDL-C remains above 3.4 mmol/L after six months of lifestyle intervention, with a target below 2.6 mmol/L. But the Royal Children’s Hospital used a higher threshold of 3.5 mmol/L, highlighting a mismatch between local practice and international guidance.

The guidelines also gave no clear direction on managing elevated triglycerides or how often to monitor abnormal results, the authors said, further complicating decisions for treating clinicians.

“Relative clinical inertia in managing hyperlipidaemia in youth with type 1 diabetes was highlighted internationally more than 15 years ago, and our data regrettably demonstrate that this continues,” the authors wrote.

Reluctance to prescribe statins in adolescents has been well documented in earlier research, the authors said. Historically, management of young patients with type 1 diabetes has focused mainly on glycaemic control rather than cardiovascular risk.

The authors argued the 2022 ISPAD guidelines, while an improvement, could be simplified further to reduce over-testing and improve adherence. They proposed focusing screening around diagnosis, to identify familial hypercholesterolaemia, and again in mid-adolescence, paired with clearer intervention triggers.

“The weight of morbidity and mortality evidence suggests cardiovascular disease needs earlier intervention,” the authors wrote. “It is imperative that clinicians adopt a more holistic approach to managing macrovascular risk in type 1 diabetes.”