Extreme hypertriglyceridemia managed with insulin

The effect of blood glucose levels on serum triglyceride clearance in patients with hyperlipidemic acute pancreatitis

Preventing moderately severe and severe acute pancreatitis (MSAP & SAP) is the primary goal of the management of hyperlipidemic acute pancreatitis (HLAP). The main aim of this study was to investigate the factors affecting serum triglyceride (TG) clearance, particularly blood glucose (GLU) levels, which could potentially help to prevent the development of MSAP & SAP. The clinical data from 177 patients with MSAP & SAP and 195 patients with mild acute pancreatitis (MAP) on days 1-6 after the onset were collected and analyzed by multivariate logistic regression to identify the factors that have an impact on the severity of HLAP, especially TG. The optimal TG threshold was obtained by receiver operating characteristic (ROC) analysis to differentiate TG fast-clearance patients from TG slow-clearance patients, as defined in this study. Metabolism-related factors that may interfere with TG clearance, such as GLU, diabetes mellitus (DM), obesity, and uric acid, were further analyzed. Day 2 TG was an independent risk factor for MSAP & SAP in patients with HLAP (OR: 3.718, 95% CI: 2.042-6.77; P < 0.001). And patients with TG slow-clearance (day 2 TG ≥ 7.335 mmol/L) were more likely to develop MSAP & SAP (sensitivity 0.932, specificity 0.898), severe pancreatic necrosis, and death. DM (OR: 3.574, 95% CI: 1.13-11.308, P < 0.001) and day 2 GLU (OR: 1.537, 95% CI: 1.292-1.675; P < 0.001) were independent risk factors for TG slow-clearance but not for HLAP severity (OR: 1.728, P = 0.253 and OR: 1.119, P = 0.059). Day 2 GLU decreased below 13.07 mmol/L and 6.575 mmol/L in patients with DM and non-diabetes mellitus (NDM), respectively, contributing to the reduction of day 2 TG to 7.335 mmol/L. Day 2 TG levels had the most impact on the severity of HLAP, which also accurately predicted the occurrence of MSAP & SAP. It is worth noting whether the GLU can reach the target value on day 2, as it can directly affect the TG clearance rate and indirectly affect the severity of HLAP.

Intravenous Insulin in Hypertriglyceridemic Pancreatitis

Hypertriglyceridemia is a rare but significant cause of pancreatitis in children. Hypertriglyceridemic pancreatitis is often correlated with more severity and complications like pancreatic necrosis. Therefore, proper management and prevention of further episodes is essential. The authors report a case of a child with hypertriglyceridemic pancreatitis who was managed with intravenous insulin. According to various case reports and case series, intravenous insulin has been found to be effective in hypertriglyceridemic pancreatitis in adults. Few case reports in children also have mentioned use of intravenous insulin in diabetic ketoacidosis with hypertriglyceridemia. The authors found intravenous insulin to be highly effective in management of pancreatitis due to severe hypertriglyceridemia in the present child.

Comparison of different intensive triglyceride-lowering therapies in patients with hyperlipidemic acute pancreatitis

OBJECTIVES

The goal of this study was to investigate the clinical value of emergent triglyceride (TG)-lowering therapies for hyperlipidemic acute pancreatitis (HLAP).

METHODS

126 HLAP patients were assigned randomly to receive either conventional treatment (CT), normal saline (NS) alone, or continuous veno-venous hemofiltration (CVVH) as an intensive TG-lowering therapy. TG levels, clinical outcomes, and inflammatory biomarkers were compared among the three groups.

RESULTS

Baseline characteristics did not differ significantly among the groups. CVVH removed TG from the plasma and achieved its target TG (<500 mg/dL) in approximately 25 h, compared to 40 h in the NS alone group and no targeted effect within 48 h in the CT group (P < 0.05). Although the majority of clinical outcomes did not differ significantly, an unexpectedly higher incidence of organ failure occurred in the CVVH group compared to the others. Hospital costs, severe AP patients and length of stay were significantly higher in the CVVH group compared to the other groups (P < 0.005).

CONCLUSIONS

Early CVVH lowers TG levels more efficiently than NS alone or CT therapy, but is not superior in terms of clinical outcomes and costs. NS also lowers TG levels and is significantly less costly than the other two treatments. Further multicenter studies are needed to determine the feasibility of NS alone treatment for HLAP patients.

Analysis of Intravenous Insulin Dosing Requirements for Treatment of Severe Hypertriglyceridemia

Purpose: Insulin infusion therapy is commonly utilized for treatment of severe hypertriglyceridemia, however, data supporting a standardized dosing approach is lacking. This study aimed to determine the average initial insulin dose utilized for treatment of hypertriglyceridemia and the associated reduction in serum triglycerides. Methods: This single-center, retrospective, descriptive analysis conducted at an academic medical center included adult hospitalized patients with serum triglyceride levels greater than 1000 mg/dL receiving treatment with an intravenous insulin infusion between November 2017 and August 2020. Data was extracted from the electronic medical record. The primary outcome was the mean weight-based intravenous insulin dose resulting in resolution of hypertriglyceridemia. Secondary outcomes included time to resolution of hypertriglyceridemia, adverse events associated with insulin treatment, incidence of rebound hypertriglyceridemia, and use of additional lipid-lowering therapies. Results: Data from 32 hospital encounters was analyzed. The mean initial triglyceride level was 3229 mg/dL. The average insulin doses observed on days 1 and 2 of therapy were 0.07 and 0.05 units/kg/hour, respectively. The mean percent triglyceride reduction at 48 hours was 40%. Mean time to resolution of hypertriglyceridemia, discontinuation of insulin infusion, or discharge was 5.7 days. Hypoglycemia and hypokalemia were observed in 9% and 29% of patients, respectively. Conclusion: The results of this study provide new guidance for insulin dosing for hypertriglyceridemia. Serum potassium levels and blood glucose should be monitored closely during therapy.

Insulin or blood purification treatment for hypertriglyceridaemia-associated acute pancreatitis: A systematic review and meta-analysis

BACKGROUND/OBJECTIVES

Hypertriglyceridaemia increases risks from acute pancreatitis (HTG-AP) over other aetiologies, but optimal management for HTG-AP remains undefined. We performed a systematic review and meta-analysis of studies of insulin-based treatment (IT) versus blood purification treatment (BPT) for HTG-AP.

METHODS

Searches were conducted to identify randomised trials and observational studies published between 1946 and 2022 that compared IT and BPT for HTG-AP reporting baseline and post-treatment serum triglyceride (TG) levels with clinical outcomes. The primary outcome was serum TG reduction (Δ-TG) from baseline while secondary outcomes included complications, length of stay, adverse events, and cost.

RESULTS

Fifteen (1 randomised, 2 prospective case-controlled, and 12 retrospective cohort) studies were analysed comprising 909 cases with HTG-AP. Pooled results demonstrated IT was significantly less efficient than BPT in Δ-TG at 24 h (WMD -666.06, 95% CI -1130.18 to -201.94, P = 0.005; 12 studies), at 48 h (WMD -672.60, 95% CI -1233.44 to -111.77; 8 studies), and overall Δ-TG by day 7 (WMD -385.81, 95% CI -711.07 to -60.54; 8 studies) (both P = 0.02). IT, however, was associated with significantly fewer adverse events (OR 0.09, 95% CI 0.03 to 0.27, P < 0.0001; 7 studies) and significantly reduced cost (WMD -2.50, 95% CI -3.61 to -1.39, P < 0.00001; 3 studies). Other secondary outcomes were not significantly different between the two regimens (all P ≥ 0.11). In subgroup analysis Δ-TG at 24 h and overall Δ-TG became insignificant, while other results were unaffected.

CONCLUSION

Our findings support the general use of IT for inpatient management of HTG-AP, restricting BPT to those predicted or found to respond poorly to IT.

Treating Hypertriglyceridemia-Induced Pancreatitis With Intravenous Insulin and Plasmapheresis

Hypertriglyceridemic pancreatitis (HTGP) is well-known but it is extremely rare, especially in younger patients. The main treatment modalities for HTGP are apheresis and intravenous insulin. However, apheresis in severe HTGP is not well established and the efficacy of the treatment is lacking. Herein, we discuss a case of a 17-year-old female patient with no significant past medical history who initially presented to the emergency department with severe diabetic ketoacidosis (DKA) and was intubated due to severe metabolic acidosis and impending respiratory failure on arrival. Further investigation showed evidence of HTGP. Initially, her condition did not improve with intravenous insulin. However, a course of apheresis along with supportive care improved her condition drastically. Hence, this is a case report which showed the efficacy of concomitant use of insulin infusion and plasmapheresis in regard to treating HTGP. Outcomes of HTGP based on different treatment modalities are discussed in this literature as well. However, to date, there are no randomized studies to draw a solid treatment algorithm, thus further research on the most efficient treatment regimes is required for the management of HTGP.

Hypertriglyceridemia-induced acute pancreatitis in children: A mini-review

Severe hypertriglyceridemia (HTG) is a known metabolic cause of acute pancreatitis (AP) in pediatric patients. The incidence of hypertriglyceridemia-induced acute pancreatitis (HTG-AP) is less well established in pediatric compared to adult patients. Studies in adults suggest that higher risk of AP occurs when triglyceride levels (TG) are >1,000 mg/dL. Most common etiologies for severe HTG in pediatric patients are either from primary hypertriglyceridemia, underlying genetic disorders of lipid and TG metabolism, or secondary hypertriglyceridemia, separate disease or exposure which affects TG metabolism. Most common theories for the pathophysiology of HTG-AP include hydrolysis of TG by pancreatic lipase to free fatty acids leading to endothelial and acinar cell damage and ischemia, as well as hyperviscosity related to increased chylomicrons. Though there are varying reports of HTG-AP severity compared to other causes of AP, a steadily growing body of evidence suggests that HTG-AP can be associated with more severe course and complications. Therapeutic interventions for HTG-AP typically involve inpatient management with dietary restriction, intravenous fluids, and insulin; select patients may require plasmapheresis. Long term interventions generally include dietary modification, weight management, control of secondary causes, and/or antihyperlipidemic medications. Though some therapeutic approaches and algorithms exist for adult patients, evidence-based management guidelines have not been well established for pediatric patients.

A Modern Approach to Dyslipidemia

Lipid disorders involving derangements in serum cholesterol, triglycerides, or both are commonly encountered in clinical practice and often have implications for cardiovascular risk and overall health. Recent advances in knowledge, recommendations, and treatment options have necessitated an updated approach to these disorders. Older classification schemes have outlived their usefulness, yielding to an approach based on the primary lipid disturbance identified on a routine lipid panel as a practical starting point. Although monogenic dyslipidemias exist and are important to identify, most individuals with lipid disorders have polygenic predisposition, often in the context of secondary factors such as obesity and type 2 diabetes. With regard to cardiovascular disease, elevated low-density lipoprotein cholesterol is essentially causal, and clinical practice guidelines worldwide have recommended treatment thresholds and targets for this variable. Furthermore, recent studies have established elevated triglycerides as a cardiovascular risk factor, whereas depressed high-density lipoprotein cholesterol now appears less contributory than was previously believed. An updated approach to diagnosis and risk assessment may include measurement of secondary lipid variables such as apolipoprotein B and lipoprotein(a), together with selective use of genetic testing to diagnose rare monogenic dyslipidemias such as familial hypercholesterolemia or familial chylomicronemia syndrome. The ongoing development of new agents-especially antisense RNA and monoclonal antibodies-targeting dyslipidemias will provide additional management options, which in turn motivates discussion on how best to incorporate them into current treatment algorithms.

Blood Purification for Hypertriglyceridemia-Induced Acute Pancreatitis: A Meta-analysis

OBJECTIVES

The purpose of our study is to investigate the efficacy and safety of blood purification (BP) therapy in hypertriglyceridemia-induced acute pancreatitis.

METHODS

We searched PubMed, Embase, Cochrane Library, and Web of Science databases for articles published.

RESULTS

The analysis included 13 studies with 934 patients (263 in BP group, 671 in control group). There was no difference in efficacy and safety between the BP group and the control group (all P > 0.05). Compared with conventional treatment, BP had shorter hospital stay (mean difference, -4.96; 95% confidence interval [CI], -8.81 to -1.11; P = 0.01) in the case of similar mortality and complications. Meanwhile, insulin treatment showed similar mortality to BP, but fewer local complications (odds risk, 2.18; 95% CI, 1.13-4.20; P = 0.02) and shorter hospital stay (mean difference, 5.46; 95% CI, 0.64-10.29; P = 0.03).

CONCLUSIONS

In the treatment of hypertriglyceridemia-induced acute pancreatitis, BP methods are effective in accelerating triglyceride level reduction and shortening hospital stay but do not affect the efficacy or reduce mortality significantly compared with conventional treatment. Insulin therapy has the same effect as BP but decreases incidence of complications and cost.

Causes, clinical findings and therapeutic options in chylomicronemia syndrome, a special form of hypertriglyceridemia

The prevalence of hypertriglyceridemia has been increasing worldwide. Attention is drawn to the fact that the frequency of a special hypertriglyceridemia entity, named chylomicronemia syndrome, is variable among its different forms. The monogenic form, termed familial chylomicronemia syndrome, is rare, occuring in 1 in every 1 million persons. On the other hand, the prevalence of the polygenic form of chylomicronemia syndrome is around 1:600. On the basis of the genetical alterations, other factors, such as obesity, alcohol consumption, uncontrolled diabetes mellitus and certain drugs may significantly contribute to the development of the multifactorial form. In this review, we aimed to highlight the recent findings about the clinical and laboratory features, differential diagnosis, as well as the epidemiology of the monogenic and polygenic forms of chylomicronemias. Regarding the therapy, differentiation between the two types of the chylomicronemia syndrome is essential, as well. Thus, proper treatment options of chylomicronemia and hypertriglyceridemia will be also summarized, emphasizing the newest therapeutic approaches, as novel agents may offer solution for the effective treatment of these conditions.

Insulin Treatment of Hypertriglyceridemia During Pregnancy

Objective: This study aims to investigate the efficiency of insulin on the reduction of gestational lipid profiles and try to propose a real-world approach to assist clinicians.

Methods: A retrospective, single-centered cohort study of 35 cases was conducted from October 2018 to July 2021 in Shanghai General Hospital. SPSS version 25.0 was performed to analyze the whole data. For continuous variables, a paired-sample t test was carried out on each variable to make a comparison between before and after treatment.

Results: The average pre-pregnancy TGs and TCs of these patients were about 3.96 ± 1.42 mmol/L and 4.78 ± 1.18 mmol/L, respectively. The maximum of TG before insulin treatment was up to 64.62 and TC 20.43 mmol/L, which decreased to 17.34 and 4.92 mmol/L after intervention of the insulin drip. TG was noticed to fall by 77% and 12.71% of TG, respectively. The difference of TG and TC between pre-treatment and post-treatment were statistically significant (p < 0.01), while this difference has not been found in the other laboratory tests reports. The outcomes of newborns and mothers with management of insulin were proven to be improved.

Conclusion: The use of insulin in the management of gestational hypertriglyceridemia is safe and efficient, and insulin may become a mainstream in the near future to mitigate serum TG and TC levels in the pregnancy period besides regulating the blood glucose level.

Lesson of the month: Acute pancreatitis due to hypertriglyceridaemia in a transgender woman: a complication of high-dose oral oestrogen therapy?

Acute pancreatitis (AP) is a medical emergency associated with significant morbidity and mortality. Hypertriglyceridaemia is a well-established but often neglected cause of AP, associated with delayed diagnosis and worse outcome than other more common causes of AP. Although oestrogen-induced hypertriglyceridaemia is known to be a rare cause of AP in females, it is much less well-recognised in biological males. We report the case of a 52-year-old transgender woman receiving high-dose oral oestrogen therapy who was admitted with abdominal pain and found to have AP caused by severe hypertriglyceridaemia. We describe the features underlying the management of AP caused by hypertriglyceridaemia and review the link between oral oestrogen, hypertriglyceridaemia and AP.Given the growth in transgender medicine leading to increasing use of therapeutic high-dose oestrogens in biological males for gender reassignment, it is important that clinicians are alert to the phenomenon of oestrogen-induced-hypertriglyceridaemia and its associated risk of AP.

Incidence and Management of Hypertriglyceridemia-Associated Acute Pancreatitis: A Prospective Case Series in a Single Australian Tertiary Centre

BACKGROUND

Hypertriglyceridemia-associated acute pancreatitis (HTGAP) has been linked with increased severity and morbidity. In this study, triglyceride levels were measured in all patients admitted with acute pancreatitis (AP) to establish the incidence of HTGAP in an Australian center.

METHODS

A prospective cohort with AP was collated over an 18-month period in a single tertiary referral hospital. HTGAP was defined as AP with triglycerides ≥ 11.2 mmol/L (1000 mg/dL). Incidence, clinical co-morbidities, severity and management strategies were recorded.

RESULTS

Of the 292 episodes of AP, 248 (85%) had triglycerides measured and were included. HTGAP was diagnosed in 10 of 248 (4%) AP cases. Type 2 diabetes, obesity, alcohol misuse and gallstones were common cofactors. The HTGAP group demonstrated severe hypertriglyceridemia compared to the non-HTGAP group (median 51 mmol/L vs. 1.3 mmol/L). Intensive care unit (ICU) admissions were significantly increased (odds ratio (OR) 16; 95% CI 4-62) in the HTGAP group (5/10 vs. 14/238 admissions, p < 0.001) and constituted 26% (5/19) of total ICU admissions for AP. Four patients received intravenous insulin with fasting and had a rapid reduction in triglyceride levels by 65-77% within 24 h; one patient had mild hypoglycemia secondary to therapy.

CONCLUSION

HTGAP occurred in 4% of AP cases and was associated with higher risk of ICU admission. Intravenous insulin and fasting appear safe and efficacious for acutely lowering triglyceride levels in HTGAP.

Lipid Management in Patients with Endocrine Disorders: An Endocrine Society Clinical Practice Guideline

OBJECTIVE

This guideline will provide the practicing endocrinologist with an approach to the assessment and treatment of dyslipidemia in patients with endocrine diseases, with the objective of preventing cardiovascular (CV) events and triglyceride-induced pancreatitis. The guideline reviews data on dyslipidemia and atherosclerotic cardiovascular disease (ASCVD) risk in patients with endocrine disorders and discusses the evidence for the correction of dyslipidemia by treatment of the endocrine disease. The guideline also addresses whether treatment of the endocrine disease reduces ASCVD risk.

CONCLUSION

This guideline focuses on lipid and lipoprotein abnormalities associated with endocrine diseases, including diabetes mellitus, and whether treatment of the endocrine disorder improves not only the lipid abnormalities, but also CV outcomes. Based on the available evidence, recommendations are made for the assessment and management of dyslipidemia in patients with endocrine diseases.

Effects of different triglyceride-lowering therapies in patients with hypertriglyceridemia-induced acute pancreatitis

The aim of the present study was to investigate the effects of various triglyceride (TG)-lowering therapies on hypertriglyceridemia-induced acute pancreatitis (HTGAP). A total of 132 patients with HTGAP were retrospectively divided into an insulin intensive therapy (IIT), a plasma exchange (PE) and a non-intensive insulin therapy (NIIT) group according to the TG-lowering therapies they had received. The clinical and biochemical data of the subjects were analyzed. The baseline data, including sex, age, TG, amylase, severe acute pancreatitis and systemic inflammatory response syndrome were not significantly different among the three groups (P>0.05). The 24-h TG clearance rate (χ²=7.74, P=0.021), onset to treatment time (χ²=14.50, P<0.001) and the time required to reach the target TG level (χ²=6.12, P=0.047) were different in these three groups, but no significant differences were observed between the IIT and NIIT groups (P>0.05). The incidence of therapy-associated complications in the PE group (30.23%) was higher than that in the IIT (2.17%) and NIIT (4.65%) groups. The difference in the incidence of therapy-associated complications was significant among the three groups (P<0.001), but no significant difference was present between the IIT and NIIT groups (P>0.05). In the PE group, the length of stay was increased compared with that in the IIT and NIIT groups (χ²=7.05, P<0.05), while there was no significant difference between the IIT and NIIT groups (P>0.05). The present study suggested that NIIT at presentation had a similar therapeutic efficacy to that of IIT to improve the prognosis of HTGAP, and NIIT and IIT were associated with fewer complications than PE treatment. NIIT may favorably perform in patients presenting early after symptom onset and may be considered for clinical application.

Conservative management in hypertriglyceridemia-associated pancreatitis

BACKGROUND

Severe hypertriglyceridemia (serum triglyceride >10 mmol L^-1 ) is implicated in ~9% of acute pancreatitis cases. Certain guidelines list severe hypertriglyceridemia as an indication for plasmapheresis.

OBJECTIVE

We assembled the natural trajectory of triglyceride levels in patients with acute pancreatitis due to severe hypertriglyceridemia who were managed conservatively without plasmapheresis to evaluate the effectiveness of this approach.

METHODS

A retrospective chart review was performed on 22 hospital admissions for acute pancreatitis episodes considered to be caused by severe hypertriglyceridemia. Patients were managed supportively, with cessation of oral intake (NPO) and intravenous hydration. Insulin infusion was used in 12 patients to manage concurrent hyperglycaemia.

RESULTS

Triglyceride levels for the group were evaluated using a mixed-effects model. The average triglyceride level fell from 45.4 mmol L^-1 on presentation to 13.3 mmol L^-1 within 48 h, corresponding to a mean 69.8% decrease. Regression analysis showed a triglyceride half-life of 30.6 h. Findings were similar for NPO-only and insulin infusion subgroups.

CONCLUSION

Patients with severe hypertriglyceridemia and acute pancreatitis can be conservatively managed safely and effectively without plasmapheresis.

Intensive insulin therapy versus plasmapheresis in the management of hypertriglyceridemia-induced acute pancreatitis (Bi-TPAI trial): study protocol for a randomized controlled trial

BACKGROUND

It is widely agreed that triglyceride (TG)-lowering therapy is imperative in early hypertriglyceridemia-induced acute pancreatitis (HTG-AP). Intravenous insulin with or without heparin, and plasmapheresis are available regimens. However, there is no consensus on first-line therapy.

METHODS/DESIGN

The Bi-TPAI trial is a multicenter, parallel group, randomized, controlled, non-inferiority trial in patients with early HTG-AP. The Bi-TPAI trial will include 220 patients with HTG-AP from 17 large tertiary hospitals in China. Patients assigned to the intensive insulin group will be administered an intravenous continuous infusion of regular human insulin at a rate of 0.1 units/kg·h and up to 0.3 units/kg·h. Patients allocated to the plasmapheresis group will receive standard-volume plasmapheresis. The primary endpoint is the time it takes for the TG level to reduce to 500 mg/dl. The secondary endpoints are ICU and hospital lengths of stay, 28-day mortality, severity of HTG-AP, incidence of hypoglycemia, HTG-AP complications, and cost-effectiveness.

DISCUSSION

The Bi-TPAI trial will prove that intensive insulin therapy is non-inferior to plasmapheresis. Intensive insulin therapy should be an effective, safe, available, and cheaper triglyceride-lowering therapy for hypertriglyceridemia-induced acute pancreatitis.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03342807 . Registered on 5 Nov 2017.

The Chylomicronemia Syndrome Is Most Often Multifactorial: A Narrative Review of Causes and Treatment

The chylomicronemia syndrome occurs when triglyceride levels are severely elevated (usually >16.95 mmol/L [1500 mg/dL]) and is characterized by such clinical features as abdominal pain, acute pancreatitis, eruptive xanthomas, and lipemia retinalis. It may result from 1 of 3 conditions: the presence of secondary forms of hypertriglyceridemia concurrent with genetic causes of hypertriglyceridemia, termed multifactorial chylomicronemia syndrome (MFCS); a deficiency in the enzyme lipoprotein lipase and some associated proteins, termed familial chylomicronemia syndrome (FCS); or familial partial lipodystrophy. Most chylomicronemia syndrome cases are the result of MFCS; FCS is very rare. In all these conditions, triglyceride-rich lipoproteins accumulate because of impaired plasma clearance. This review describes the 3 major causes of the chylomicronemia syndrome; their consequences; and the approaches to treatment, which differ considerably by group.

A systematic review of the epidemiology, pathophysiology and current management of hyperlipidaemic pancreatitis

BACKGROUND & AIMS

The aims of this systematic review were to define the epidemiology and pathophysiology of hyperlipidaemic pancreatitis, establish its association with clinical outcome and define management strategies.

METHODS

The Cochrane, Embase and Medline databases were searched, limited to the last decade, for articles on hyperlipidaemic pancreatitis. All randomised controlled trials, observational studies and case series (with a minimum of 10 patients) on hyperlipidaemic pancreatitis were included.

RESULTS

Thirty-eight studies with 1979 patients were included. The median admission triglyceride concentration was 42.8 mmol/L (range 13.6-108.6 mmol/L) [3785 mg/dL (range 1205-9612 mg/dL)]. Severe hypertriglyceridaemia (>1000 mg/dL, 11.0 mmol/L) was present in 1.7% of the adult population, and about 15-20% of these developed hyperlipidaemic acute pancreatitis. Medical management of severe hyperlipidaemia at onset of acute pancreatitis has not been investigated fully. However, tight regulation of triglyceride concentration after presentation with acute pancreatitis was found to reduce the risk of recurrence. Plasmapheresis reduced concentrations of triglycerides by up to 85%, but this did not impact morbidity or mortality. All studies included defined hyperlipidaemia as a more severe form of pancreatitis.

CONCLUSION

The available evidence suggests an increasing risk of acute pancreatitis in patients with hyperlipidaemia and a more severe form of pancreatitis. There is some evidence to suggest biochemical benefit of using novel techniques like plasmapheresis without the desired physiological benefit. However, there is a need for an international consensus on the management of hyperlipidaemic pancreatitis. More rigorous and methodologically robust studies are required to inform such consensus guidelines.

Hypertriglyceridemia-induced pancreatitis: updated review of current treatment and preventive strategies

Hypertriglyceridemia (HTG) is an uncommon but well-established cause of acute pancreatitis (AP) comprising up to 7% of the cases. The clinical course of HTG-induced pancreatitis (HTGP) is highly similar to that of AP of other etiologies with HTG being the only distinguishing clinical feature. However, HTGP is often correlated with higher severity and elevated complication rate. At present, no approved treatment guideline for the management of HTGP is available, although different treatment modalities such as insulin, heparin, fibric acids, and omega 3 fatty acids have been successfully implemented to reduce serum triglycerides (TG). Plasmapheresis has also been used to counteract elevated TG levels in HTGP patients. However, it has been associated with complications. Following the management of acute phase, lifestyle modifications including dietary adjustments and drug therapy are essential in the long-term management of HTGP and the prevention of its relapse. Results from studies of small patient groups describing treatment and prevention of HTGP are not sufficient to draw solid conclusions resulting in no treatment algorithm being available for effective management of HTGP. Therefore, prospective randomized, active-controlled clinical studies are required to find a better treatment regimen for the management of HTGP. Until date, one randomized clinical trial has been performed to compare clinical outcomes of different treatment approaches for HTGP. However, further studies are required to outline a generalized and efficient treatment regimen for the management of HTGP.

Hypertriglyceridemia in Diabetes Mellitus: Implications for Pediatric Care

Cardiovascular disease (CVD) is the leading cause of morbidity and mortality in type 1 diabetes mellitus (T1DM) and type 2 diabetes mellitus (T2DM). It is estimated that the risk of CVD in diabetes mellitus (DM) is 2 to 10 times higher than in the general population. Much of this increased risk is thought to be related to the development of an atherogenic lipid profile, in which hypertriglyceridemia is an essential component. Recent studies suggest that dyslipidemia may be present in children and adolescents with DM, particularly in T2DM and in association with poor control in T1DM. However, the role of hypertriglyceridemia in the development of future CVD in youth with DM is unclear, as data are scarce. In this review, we will evaluate the pathophysiology of atherogenic hypertriglyceridemia in DM, the evidence regarding an independent role of triglycerides in the development of CVD, and the treatment of hypertriglyceridemia in patients with DM, highlighting the potential relevance to children and the need for more data in children and adolescents to guide clinical practice.

Approach to Hypertriglyceridemia in the Pediatric Population

Hypertriglyceridemia is increasingly identified in children and adolescents, owing to improved screening and higher prevalence of childhood obesity. Hypertriglyceridemia can result from either increased triglyceride (TG) production or reduced TG clearance. The etiologic origin can be primary (genetic) or secondary, but it is often multifactorial. Management is challenging because of the interplay of genetic and secondary causes and lack of evidence-based guidelines. Lifestyle changes and dietary interventions are most important, especially in hypertriglyceridemia associated with obesity. Dietary restriction of fat remains the mainstay of management in primary hypertriglyceridemia. When fasting TG concentration is increased above 500 mg/dL (5.65 mmol/L), fibrates may be used to prevent pancreatitis. Omega-3 fatty acids are often used as an adjunctive therapy. When the fasting TG concentration is less than 500 mg/dL (5.65 mmol/L) and if the non-high-density lipoprotein cholesterol level is above 145 mg/dL (3.76 mmol/L), statin treatment can be considered.

Treatment of Hypertriglyceridemia-Induced Acute Pancreatitis With Insulin, Heparin, and Gemfibrozil: A Case Series

Hypertriglyceridemia is the third most common worldwide cause of acute pancreatitis. Resolving the underlying etiology is imperative for optimal management. This is especially true with regard to hypertriglyceridemia, as this etiology may cause more severe acute pancreatitis and worse symptoms than other causes of the disease. Many pharmacological treatment options for hypertriglyceridemia-induced acute pancreatitis (HTGP) have been proposed; however, the safety and efficacy for specific treatment regimens remain nebulous. At our institution, 6 patients, whose average Ranson criteria score were 5 and presenting triglyceride concentrations were 3501 mg/dL, were managed with a continuous infusion of insulin, subcutaneous heparin, and oral gemfibrozil for HTGP. Maximum insulin infusion rates ranged from 0.8 to 20.9 U/h. Half of the patients received nongemfibrozil cholesterol medication. Five patients experienced a resolution of HTGP (median day 3). The only adverse drug event was hypoglycemia in a single patient. Combination therapy with heparin, insulin, and gemfibrozil is safe and efficacious in quickly lowering serum triglyceride concentrations in HTGP. This combination warrants further study.

Presentation and management of acute hypertriglyceridemic pancreatitis in pregnancy: A case report

Pancreatitis related to hypertriglyceridemia can occasionally occur during pregnancy, particularly if there are underlying genetic abnormalities in lipid metabolism. We report the case of a 27-year-old female with hypertriglyceridemic pancreatitis in pregnancy that was treated initially with lipid lowering medications, followed by plasma exchange for persistently elevated triglyceride levels. Despite multiple interventions, she developed recurrent pancreatitis and simultaneously had a preterm birth. In this case report, we highlight the various therapies and the use of plasmapharesis in secondary prevention of hypertriglyceridemic pancreatitis in pregnancy.

Chylomicronaemia--current diagnosis and future therapies

This Review discusses new developments in understanding the basis of chylomicronaemia--a challenging metabolic disorder for which there is an unmet clinical need. Chylomicronaemia presents in two distinct primary forms. The first form is very rare monogenic early-onset chylomicronaemia, which presents in childhood or adolescence and is often caused by homozygous mutations in the gene encoding lipoprotein lipase (LPL), its cofactors apolipoprotein C-II or apolipoprotein A-V, the LPL chaperone lipase maturation factor 1 or glycosylphosphatidylinositol-anchored high density lipoprotein-binding protein 1. The second form, polygenic late-onset chylomicronaemia, which is caused by an accumulation of several genetic variants, can be exacerbated by secondary factors, such as poor diet, obesity, alcohol intake and uncontrolled type 1 or type 2 diabetes mellitus, and is more common than early-onset chylomicronaemia. Both forms of chylomicronaemia are associated with an increased risk of life-threatening pancreatitis; the polygenic form might also be associated with an increased risk of cardiovascular disease. Treatment of chylomicronaemia focuses on restriction of dietary fat and control of secondary factors, as available pharmacological therapies are only minimally effective. Emerging therapies that might prove more effective than existing agents include LPL gene therapy, inhibition of microsomal triglyceride transfer protein and diacylglycerol O-acyltransferase 1, and interference with the production and secretion of apoC-III and angiopoietin-like protein 3.