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Izar MCDO, Santos Filho RDD, Assad MHV, Chagas ACP, Toledo Júnior ADO, Nogueira ACC, Souto ACCF, Lottenberg AMP, Chacra APM, Ferreira CEDS, Lourenço CM, Valerio CM, Cintra DE, Fonseca FAH, Campana GA, Bianco HT, Lima JGD, Castelo MHCG, Scartezini M, Moretti MA, Barreto NSF, Maia RE, Montenegro Junior RM, Alves RJ, Figueiredo RMM, Fock RA, Martinez TLDR. Brazilian Position Statement for Familial Chylomicronemia Syndrome - 2023. Arq Bras Cardiol 2023; 120:e20230203. [PMID: 37075362 PMCID: PMC10348387 DOI: 10.36660/abc.20230203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2023] Open
Affiliation(s)
| | | | | | | | | | | | | | - Ana Maria Pitta Lottenberg
- Laboratório de Lípides (LIM 10) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
- Hospital Israelita Albert Einstein (HIAE), São Paulo, SP - Brasil
| | - Ana Paula Marte Chacra
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | | | - Cynthia Melissa Valerio
- Instituto Estadual de Diabetes e Endocrinologia Luiz Capriglione (IEDE-RJ), Rio de Janeiro, RJ - Brasil
| | | | | | | | | | - Josivan Gomes de Lima
- Hospital Universitário Onofre Lopes da Universidade Federal do Rio Grande do Norte (UFRN), Natal, RN - Brasil
| | | | | | - Miguel Antonio Moretti
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | | | - Renan Magalhães Montenegro Junior
- Complexo Hospitalar da Universidade Federal do Ceará (UFCE), Empresa Brasileira de Serviços Hospitalares (EBSERH), Fortaleza, CE - Brasil
| | - Renato Jorge Alves
- Hospital Santa Casa de Misericórdia de São Paulo, São Paulo, SP - Brasil
| | - Roberta Marcondes Machado Figueiredo
- Hospital Israelita Albert Einstein (HIAE), São Paulo, SP - Brasil
- Faculdade Israelita de Ciências da Saúde Albert Einstein (FICSAE), São Paulo, SP - Brasil
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Abstract
Hypertriglyceridemia is one of the most common lipid abnormalities encountered in clinical practice. Many monogenic disorders causing severe hypertriglyceridemia have been identified, but in most patients triglyceride elevations result from a combination of multiple genetic variations with small effects and environmental factors. Common secondary causes include obesity, uncontrolled diabetes, alcohol misuse, and various commonly used drugs. Correcting these factors and optimizing lifestyle choices, including dietary modification, is important before starting drug treatment. The goal of drug treatment is to reduce the risk of pancreatitis in patients with severe hypertriglyceridemia and cardiovascular disease in those with moderate hypertriglyceridemia. This review discusses the various genetic and acquired causes of hypertriglyceridemia, as well as current management strategies. Evidence supporting the different drug and non-drug approaches to treating hypertriglyceridemia is examined, and an easy to adopt step-by-step management strategy is presented.
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Affiliation(s)
- Vinaya Simha
- Division of Endocrinology, Mayo Clinic, Rochester, MN 55905, USA
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Abstract
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.
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Affiliation(s)
- Badhma Valaiyapathi
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, AL
| | - Bhuvana Sunil
- Department of Pediatrics, Harlem Hospital Center, New York, NY
| | - Ambika P Ashraf
- Division of Pediatric Endocrinology and Metabolism, Department of Pediatrics, Children's of Alabama, University of Alabama at Birmingham, Birmingham, AL
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Valdivielso P, Ramírez-Bueno A, Ewald N. Current knowledge of hypertriglyceridemic pancreatitis. Eur J Intern Med 2014; 25:689-94. [PMID: 25269432 DOI: 10.1016/j.ejim.2014.08.008] [Citation(s) in RCA: 249] [Impact Index Per Article: 24.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2014] [Revised: 08/19/2014] [Accepted: 08/20/2014] [Indexed: 12/21/2022]
Abstract
Severe hypertriglyceridemia (HTG) is a well established and the most common cause of acute pancreatitis (AP) after alcohol and gall stone disease. It is alleged to account for up to 10% of all pancreatitis episodes. Studies suggest that in patients with triglyceride (TG) levels>1000 mg/dL (>11.3 mmol/L), hypertriglyceridemia-induced acute pancreatitis (HTGP-AP) occurs in approximately 15-20% of all subjects referred to Lipid Clinics. Until now, there is no clear evidence which patients with severe HTG will develop pancreatitis and which will not. Underlying pathophysiological concepts include hydrolysis of TG by pancreatic lipase and excessive formation of free fatty acids with inflammatory changes and capillary injury. Additionally hyperviscosity and ischemia may play a decisive role. The clinical features of HTG-AP patients are supposed to be no different from patients with AP of other etiologies. Yet, there are well-conducted studies suggesting that HTG-AP is associated with a higher severity and complication rate. Therapeutic measurements in HTG-AP include dietary modifications, different antihyperlipidemic agents, insulin and/or heparin treatment. The beneficial use of plasmapheresis is repeatedly reported and suggested in many studies. Yet, due to the lack of randomized and controlled trials, it is currently unknown if plasmapheresis may improve morbidity and mortality in the clinical setting of HTG-AP. Since there are no commonly accepted clinical guidelines in the management of HTG-AP, there is a definite need for an international, multicenter approach to this important subject.
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Affiliation(s)
- Pedro Valdivielso
- Department of Medicine and Dermatology, University of Malaga, Spain; Servicio de Medicina Interna, Hospital Virgen de la Victoria, Malaga, Spain
| | - Alba Ramírez-Bueno
- Servicio de Medicina Interna, Hospital Virgen de la Victoria, Malaga, Spain
| | - Nils Ewald
- Justus-Liebig-University Giessen, 35392 Giessen, Germany; General Hospital Luebbecke-Rahden, Department of Internal Medicine, 32312 Luebbecke, Germany.
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Thuzar M, Shenoy VV, Malabu UH, Schrale R, Sangla KS. Extreme hypertriglyceridemia managed with insulin. J Clin Lipidol 2014; 8:630-634. [PMID: 25499946 DOI: 10.1016/j.jacl.2014.09.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2014] [Revised: 08/22/2014] [Accepted: 09/11/2014] [Indexed: 01/07/2023]
Abstract
Extreme hypertriglyceridemia can lead to acute pancreatitis and rapid lowering of serum triglycerides (TG) is necessary for preventing such life-threatening complications. However, there is no established consensus on the acute management of extreme hypertriglyceridemia. We retrospectively reviewed 10 cases of extreme hypertriglyceridemia with mean serum TG on presentation of 101.5 ± 23.4 mmol/L (8982 ± 2070 mg/dL) managed with insulin. Serum TG decreased by 87 ± 4% in 24 hours in those patients managed with intravenous insulin and fasting and 40 ± 8.4% in those managed with intravenous insulin alone (P = .0003). The clinical course was uncomplicated in all except 1 patient who subsequently developed a pancreatic pseudocyst. Thus, combination of intravenous insulin with fasting appears to be an effective, simple, and safe treatment strategy in immediate management of extreme hypertriglyceridemia.
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Affiliation(s)
- Moe Thuzar
- Department of Endocrinology and Diabetes, The Townsville Hospital, Queensland, Australia; University of Queensland, Australia.
| | - Vasant V Shenoy
- Department of Endocrinology and Diabetes, The Townsville Hospital, Queensland, Australia; James Cook University, Queensland, Australia
| | - Usman H Malabu
- Department of Endocrinology and Diabetes, The Townsville Hospital, Queensland, Australia; James Cook University, Queensland, Australia
| | - Ryan Schrale
- James Cook University, Queensland, Australia; Department of Cardiology, The Townsville Hospital, Queensland, Australia
| | - Kunwarjit S Sangla
- Department of Endocrinology and Diabetes, The Townsville Hospital, Queensland, Australia; James Cook University, Queensland, Australia.
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Abraham M, Mitchell J, Simsovits D, Gasperino J. Hypertriglyceridemic Pancreatitis Caused by the Oral Contraceptive Agent Estrostep. J Intensive Care Med 2014; 30:303-7. [PMID: 24671004 DOI: 10.1177/0885066614528083] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2013] [Accepted: 01/13/2014] [Indexed: 12/18/2022]
Abstract
Norethindrone acetate/ethinyl estradiol (Estrostep; Warner Chilcott, Rockaway, New Jersey) is an "estrophasic" type of oral contraceptive, which combines a continuous low progestin dose with a gradually increasing estrogen dose. In clinical trials, this medication failed to produce clinically significant changes in serum lipid levels. We report a case of severe hypertriglyceridemia-induced acute pancreatitis in a 24-year-old woman caused by Estrostep, occurring nearly 10 years after she began using the drug. The patient was admitted to the medical intensive care unit (ICU) for aggressive volume resuscitation and management of severe electrolyte abnormalities. Laboratory studies obtained on admission indicated severe hypertriglyceridemia (2,200 mg/dL), hyponatremia (120 mEq/L), and hypocalcemia (0.78 mmol/L). Amylase and lipase levels were also elevated (193 and 200 U/L, respectively). Ranson score calculated after 48 hours of admission was 4, and her Acute Physiology and Chronic Health Evaluation (APACHE) IV score was 35. Treatment included an insulin infusion, ω-3 fatty acid esters, and gemfibrozil. The insulin infusion reduced serum triglyceride levels by 50% after 1 day of treatment and to 355 mg/dL by day 7 of her ICU course. We believe that this is the first reported case of severe, acute hypertriglyceridemia-induced pancreatitis caused by this medication.
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Affiliation(s)
- Mary Abraham
- Department of Medicine, Section of Critical Care Medicine, Drexel University College of Medicine, Philadelphia, PA, USA
| | - Jennifer Mitchell
- Department of Medicine, Section of Critical Care Medicine, Drexel University College of Medicine, Philadelphia, PA, USA
| | - Debra Simsovits
- Department of Medicine, Section of Critical Care Medicine, Drexel University College of Medicine, Philadelphia, PA, USA
| | - James Gasperino
- Department of Medicine, Section of Critical Care Medicine, Drexel University College of Medicine, Philadelphia, PA, USA
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Henderson SR, Maitland R, Mustafa OG, Miell J, Crook MA, Kottegoda SR. Severe hypertriglyceridaemia in Type 2 diabetes mellitus: beneficial effect of continuous insulin infusion. QJM 2013; 106:355-9. [PMID: 23417910 DOI: 10.1093/qjmed/hcs238] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Severe hypertriglyceridaemia is a recognized complication of Type 2 diabetes mellitus (T2DM); however, there is no consensus on acute management despite the significant risk of developing associated complications such as acute pancreatitis and hyperviscosity syndrome. AIM To identify the association between hyperglycaemia and severe hypertriglyceridaemia in patients with T2DM and assess the effect of continuous insulin infusion therapy on serum triglyceride (TG) concentrations and report any adverse events associated with this therapeutic approach. DESIGN Retrospective review of case records. METHODS Patients with uncontrolled hyperglycaemia and severe hypertriglyceridaemia (serum TG > 15 mmol/l) treated with continuous intravenous insulin infusion between October 2008 and September 2009 were retrospectively evaluated (n = 15). Details recorded included demographics, admission details, lipid profiles, glycaemic control, serum amylase and adverse events. Patients receiving treatment-dose unfractionated heparin infusion were excluded. RESULTS Severe hypertriglyceridaemia is associated with hyperglycaemia in our heterogeneous group of patients with T2DM presenting with new-onset diabetes or established disease on pre-existing insulin or oral hypoglycaemic agents. Administration of continuous exogenous insulin not only achieved normoglycaemia but also dramatically corrected severe hypertriglyceridaemia in all patients (P = 0.001). CONCLUSION The administration of continuous insulin in patients with T2DM with severe hypertriglyceridaemia is a simple and safe method of significantly reducing the immediate risk associated with this metabolic complication and should be considered in any T2DM patient presenting with severe hypertriglyceridaemia and hyperglycaemia.
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Abstract
Environmental and lifestyle changes have led to an increasing incidence of primary or secondary high triglycerides. As elevated triglycerides are an important risk factor for acute pancreatitis (AP), the incidence of AP of this cause has also been gradually increasing. Patients with hyperlipidemic AP often suffer severely and develop more complications. Crucial therapy is to lower serum triglyceride levels. In this article, we will summarize the recent progress in the treatment of hyperlipidemic pancreatitis.
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