Hypertriglyceridemia

Background

  • ~5% of acute pancreatitis caused by high triglycerides[1]
  • Etiologies
    • Familial hypertriglyceridemia, autosomal dominant with variable penetrance
    • Secondary forms
  • TG levels > 2000mg/dL almost always have both secondary and genetic form[2]
  • 1.7% of US estimated to have [TG] between 500-2000[3]
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  • May present with normal serum lipase levels

Pathophysiology

  • Excess TG hydrolyzed by increased concentration of pancreatic lipase
  • Produces increased concentration of free fatty acids that exceeds binding capacity of albumin
  • Micelles are formed that attack platelets, vascular endothelium and acinar cells
  • Ischemia and pancreatic injury result
  • An acidic environment potentiates free fatty acid toxicity

Management of Pancreatitis

  • Evidence for management based on case series and reports[4][5]
  • Insulin drip - most dramatic and rapid intervention, with reduction within 24 hrs
    • 5-10 units/hr with or without dextrose infusion to maintain BSs ~150mg/dL
    • May require higher dosages for diabetics, 0.1–0.3 U/kg/hr
    • Titrate to BS 140–180mg/dL[6]
  • Treat concurrent hypothyroidism if present
  • Niacin 500mg QD
  • Gemfibrozil or fenofibrate
  • Max dose statin, 81mg ASA
  • Heparin q8 SC, effect short-lived
  • NPO initially
  • May advance diet starting at TG level < 1000mg/dL with resolution of abdominal pain/pancreatitis symptoms
    • No fat diet
    • Low calorie diet
  • Follow TG levels, goal < 500-1000mg/dL by discharge

Plasma exchange

  • Therapeutic plasma exchange, for 1-3 days
  • For euglycemic patients, not routine first line
  • Requires central venous access

Disposition

  • ICU or step-down for frequent labs, insulin drip

References

  1. Yadav D, Pitchumoni CS. Issues in hyperlipidemic pancreatitis. J Clin Gastroenterology 2003;36:54-62.
  2. Yuan et al. Hypertriglyceridemia: its etiology, effects and treatment. CMAJ 2007;176:1113-1120.
  3. Brown, Virgil W. Et al. “Clinical Lipidology Roundtable Discussion: Severe Hypertriglyceridemia.” Journal of Clinical Lipidology 2012; 6:397-408
  4. Santana YR et al. Treatment of severe hypertriglyceridemia with continuous insulin infusion. Case Reports in Critical Care. June 2011.
  5. Poonuru S et al. Rapid Reduction of Severely Elevated Serum Triglycerides with Insulin Infusion, Gemfibrozil and Niacin. Clin Med Res. 2011 Mar; 9(1): 38–41.
  6. Schaefer EW. Management of Severe Hypertriglyceridemia in the Hospital: A Review. Journal of Hospital Medicine Vol 7|No 5|May/June 2012.