Lipid-lowering medications used in pediatric practice

Drug	Starting dose	Maximal dose
Statins
Atorvastatin	Age 6 to <10 years: 5 mg orally once daily Age ≥10 years: 10 to 20 mg orally once daily	Usual maximal dose: 40 mg/day Doses up to 80 mg/day are sometimes used
Fluvastatin	20 mg orally once daily	40 mg twice daily (80 mg/day)
Lovastatin	10 mg orally once daily	80 mg/day
Pitavastatin	2 mg orally once daily	4 mg/day
Pravastatin	10 to 20 mg orally once daily	Usual maximal dose: 40 mg/day Doses up to 80 mg/day are sometimes used
Rosuvastatin	5 to 10 mg orally once daily	Usual maximal dose: 20 mg/day Doses up to 40 mg/day are sometimes used
Simvastatin	Age 4 to <10 years: 5 mg orally once daily (limited data) Age ≥10 years: 10 mg orally once daily	Age 4 to <10 years: 20 mg/day (limited data) Age ≥10 years: 40 mg/day
Cholesterol absorption inhibitor
Ezetimibe	10 mg orally once daily	10 mg/day
Bile acid sequestrants
Cholestyramine	Fixed dosing: 2 to 4 g orally once daily or in 2 to 3 divided doses with meals Weight-based dosing: 240 mg/kg orally once daily or in 2 to 3 divided doses with meals	Age 6 to <10 years: 4 g/day Age ≥10 years: 8 g/day
Colestipol	Fixed dosing: 2.5 to 5 g orally once daily or in 2 divided doses Weight-based dosing: 125 to 250 mg/kg orally once daily or in 2 divided doses	12 g/day
Colesevelam	1.25 g orally once daily or in 2 divided doses	3.75 g/day
Fibric acid derivates
Fenofibrate	Limited pediatric data Adult dosing: 30 to 67 mg orally once daily	90 to 200 mg/day (maximum dose depends on preparation; refer to drug reference included within UpToDate)
Gemfibrozil	Limited pediatric data Adult dosing: 600 mg orally twice daily	1200 mg/day
Marine omega-3 fatty acids
Icosapent ethyl	Pediatric data are lacking Adult dosing: 1 to 2 g orally twice daily	4 g/day
Omega-3 acid ethyl esters	1 to 2 g orally twice daily	4 g/day
Use of the following agents in pediatric patients is mostly limited to patients with FH (or similar genetic lipid disorder)
PCSK9 inhibitors
Alirocumab	<50 kg: 150 mg SUBQ once every 4 weeks, or 75 mg SUBQ once every 2 weeks ≥50 kg: 300 mg SUBQ once every 4 weeks, or 150 mg SUBQ once every 2 weeks	<50 kg: 150 mg/dose ≥50 kg: 300 mg/dose
Evolocumab	420 mg SUBQ every 4 weeks, or 140 mg SUBQ every 2 weeks	420 mg/dose
Other agents
Evinacumab	15 mg/kg IV infusion once every 4 weeks	15 mg/kg/dose
Lomitapide	Pediatric data are lacking Adult dosing: 5 mg orally once daily	60 mg/day
Bempedoic acid	Pediatric data are lacking Adult dosing: 180 mg orally once daily	180 mg/day

This table summarizes lipid-lowering agents that are used in the management of pediatric dyslipidemia. It is intended for use in conjunction with additional content. For further details, including a discussion of the indications for lipid-lowering drug therapy, refer to UpToDate's topics on management of pediatric dyslipidemia and FH.

Important considerations when using this table include:

Pharmacologic therapy for pediatric dyslipidemia is generally reserved for children ≥10 years unless the child has a severe form of hypercholesterolemia (eg, homozygous FH) or other condition that places them at high risk for ASCVD. Children <10 years old who require pharmacologic lipid-lowering therapy should be referred to a pediatric lipid specialist.
Statins are the mainstay of therapy for hypercholesterolemia (ie, elevated LDL-C). When a second agent is necessary, ezetimibe is generally the preferred choice. Marine omega-3 fatty acids and fibric acid derivatives are sometimes used to treat severe hypertriglyceridemia in children and adolescents. Other agents (eg, PCSK9 inhibitors, evinacumab, lomitapide, and bempedoic acid) are primarily used in patients with severe hypercholesterolemia due to a genetic lipid disorder (eg, FH). Patients requiring these therapies should be managed by a pediatric lipid specialist. For additional details on indications for lipid-lowering therapy and guidance on choice of agent, refer to UpToDate's topics on pediatric dyslipidemia and FH.
For oral lipid-lowering agents that are given once daily, it is generally preferable to give the dose at bedtime since most LDL-C synthesis occurs overnight.
Doses listed are for patients with normal kidney and liver function. Doses may need to be modified in kidney or hepatic impairment; refer to UpToDate Lexidrug monographs for details.
Medications in this table are subject to numerous drug interactions; when initiating or altering drug therapy, use of a drug interactions program is advised.

ASCVD: atherosclerotic cardiovascular disease; FH: familial hypercholesterolemia; IV: intravenous; LDL-C: low-density lipoprotein cholesterol; PCSK9: proprotein convertase subtilisin/kexin type 9; SUBQ: subcutaneous.

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Lipid-lowering medications used in pediatric practice