Clinical Practice Recommendations for Pediatric Dyslipidemia

The leading cause of mortality in the United States is atherosclerotic cardiovascular disease (ASCVD). Atherosclerotic lesions begin during childhood and can place individuals at greater risk for ASCVD. Providers play an active role in preventing the progression of risk factors and future ASCVD events through appropriate clinical management of genetic and acquired dyslipidemias in the pediatric population. Health care providers need to be aware of current recommendations related to screening for dyslipidemia, lifestyle modification strategies, pharmacologic treatment, and guidelines for ongoing monitoring. Most patients with mild to moderate dyslipidemia can be managed by a primary care provider. It is imperative that providers understand the pathophysiology, screening methods, and available treatment options to effectively manage the condition. Frequent reassessment of family history and adherence to lifestyle modifications and pharmacologic interventions is essential for effective treatment.

Chewing the Fat: A Case Report of Therapeutic Plasma Exchange in Hypertriglyceridemia-Induced Pancreatitis

Hypertriglyceridemia is the third most common etiology of acute pancreatitis, but lacks a clear, evidence-based treatment approach. We present the case of a 25-year-old man who was admitted eleven times over seven years for hypertriglyceridemia-induced pancreatitis. In his first ten admissions, he received conservative therapy. During his eleventh admission, he underwent therapeutic plasma exchange with lowering of serum triglycerides from 5080 to 332 mg/dL. He was discharged on hospital day five and was noted to have persistently lowered triglyceride levels upon follow up. The case affirms plasma exchange's ability to rapidly lower serum triglyceride levels and provides future research opportunities for examining the long-term effects of this treatment.

[Primary hyperchylomicronemia]

Primary hyperchylomicronemia is characterized by a marked hypertriglyceridemia due to an increase in chylomicrons, which may cause acute pancreatitis and eruptive xanthomas. This entity includes familial lipoprotein lipase (LPL) deficiency, familial apolipoprotein C-II deficiency, primary type V hyperlipoproteinemia, and idiopathic hyperchylomicronemia. Idiopathic hyperchylomicronemia is caused by an LPL inhibitor or autoantibody against LPL. More recently, patients with primary hyperchylomicronemia caused by mutations in the gene for glycosylphosphatidylinositol-anchored high density lipoprotein-binding protein 1(GPIHBP1) or lipase maturation factor 1(LMF1). For the treatment of primary hyperchylomicronemia, a strict restriction of dietary fat is essential to avoid acute pancreatitis.

Monogenic pediatric dyslipidemias: classification, genetics and clinical spectrum

Monogenic disorders that cause abnormal levels of plasma cholesterol and triglycerides have received much attention due to their role in metabolic dysfunction and cardiovascular disease. While these disorders often present clinically during adulthood, some present most commonly in the pediatric population and can have serious consequences if misdiagnosed or untreated. This review provides an overview of monogenic lipid disorders that present with unusually high or low levels of plasma cholesterol and/or triglycerides during infancy, childhood and adolescence. Biochemical and genetic findings, clinical presentation and treatment options are discussed with an emphasis upon recent advances in our understanding and management of these monogenic disorders.

[Excessive hyperchylomicronemia--a rare cause of acute retrosternal and epigastric pain in pregnancy]

CASE REPORT

A 24-year-old woman in her 13th gestational was admitted to our department with acute retrosternal and epigastric pain. She had been transferred from the gynecologic department where she was treated for vaginal bleeding because of abortus imminens. A cardiac cause was excluded by ECG and echo. Clinical chemistry and abdominal ultrasound confirmed the diagnosis of acute pancreatitis. The woman was known in our outpatient department for hyperchylomicronemia and had already had an earlier episode of acute pancreatitis under oral contraception years ago. At current admission, triglycerides were 11,500 mg/dl. To reduce plasma triglycerides, selective lipid apheresis was performed. Apheresis was well tolerated, and the patient became free of pain within the first 30 min of treatment. Triglycerides decreased to 6,600 mg/dl at this session. Keeping to a low-fat diet (< 30 g fat per day), the patient remained healthy and completed pregnancy with the delivery of a healthy girl in her 39th week of pregnancy.

CONCLUSION

Selective lipid apheresis is a safe and effective option in the treatment of hyperlipidemic pancreatitis, even in pregnant patients.

Asymptomatic massive hypertriglyceridemia in an octogenarian

OBJECTIVE

To report the case of an 85-year-old man with asymptomatic massive hypertriglyceridemia (MHTG).

CLINICAL PRESENTATION AND INTERVENTION

Our case was a non-smoker, healthy 85-year-old Caucasian male, with no excessive alcohol intake and no evidence of an excessive sedentary lifestyle, body mass index = 23.2 kg/m(2), BP = 125/85 mm Hg and plasma triglyceride (TG) >1,000 mg/dl. The MHTG was an incidental finding at the age of 70. He had no cardiovascular disease, xanthomas, xanthelasmas or keratic precipitate. During the last 15 years, his average TG plasma levels showed a significant variability independent of specific diet treatment and fibrate therapy. Liver ultrasound examination excluded hepatomegaly and fatty degeneration. Carotid artery ultrasound showed only intimal thickening in both carotid bifurcations.

CONCLUSION

In this patient, MHTG had been silent for many years, with no evidence of coronary heart disease and liver fatty degeneration, both typical complications present in MHTG subjects with low high-density lipoprotein. Hence, this case must be considered as a rarity.

Hypertriglyceridemia in a 5-day-old newborn--a case report

Neonatal hypertriglyceridaemia is extremely rare in pediatrics. We narrowed down the possibilities to a case of lipoprotein lipase (LPL) deficiency through a designed process of elimination with this particular patient. The biochemical hallmark of the disease is the presence of hyperchylomicronemia in fasting plasma. The patient responded well to a special formula containing median chain triglyceride (MCT). This was one of the youngest cases of hyperlipidemia and hyperlipoproteinemia to be reported during the neonatal period. Therefore the approach is mainly through the process of elimination because of inadequate laboratory facilities.

[Effect of omega-3-fatty acids on lipoprotein metabolism. Different effects in various phenotypes]

A review of the literature confirms a regular and significant lowering of serum triglycerides by omega-3 fatty acids. This effect is the more pronounced the higher the initial levels are. Accordingly, in type V hyperlipoproteinemia, it is particularly marked. In normolipemic subjects and in patients with hypercholesterolemia (type IIA), total cholesterol is only slightly reduced. In patients with elevation of cholesterol and triglycerides (types IIB, IV and V), both triglycerides and cholesterol are lowered. This decrease is mainly obtained by reduction in VLDL cholesterol. In the case of types IV and V, on the other hand, triglyceride reduction is associated with an elevation of LDL and HDL cholesterol. At present, it is not clear whether the increase in LDL cholesterol is of a transient nature and prognostically irrelevant. It can be prevented by reducing the intake of saturated fat. HDL cholesterol is decreased by high doses and increased by low doses of omega-3 fatty acids. In the differential treatment of hyperlipoproteinemias, consideration should be given to these points.

Effect of low dose supplementation of L-carnitine on lipid metabolism in hemodialyzed children

Long-term intravenous supplementation with low dose L-carnitine (5 mg/kg body wt) was investigated in seven hemodialyzed children with type IV hyperlipoproteinemia. Carnitine was given at the completion of each hemodialysis treatment (3 times a week) over a period of five months. This treatment resulted in a rise in total plasma carnitine concentrations (117.7 +/- 33.0 microM) as compared to before therapy (37.9 +/- 15.8 microM); the free fraction was the chief portion of this elevation. Prior to therapy the patients had high plasma triglyceride concentrations (3.82 +/- 1.6 mM) which were markedly reduced after five months of carnitine therapy (1.86 +/- 0.7 mM; P less than or equal to 0.05). The initially low HDL-cholesterol levels (0.91 +/- 0.2 mM) were increased (1.13 +/- 0.2 mM; P less than or equal to 0.05) after supplementation. Thus, long-term low-dose carnitine supplementation improves the disturbed lipid metabolism; this suggests an important role for carnitine in uremic children and may justify the use of supplemental carnitine.

[Correction of hypercholesterolemia and dyslipoproteinemia by plasmapheresis in patients with stenocardia resistant to drug therapy]

Plasmapheresis was used to correct blood lipid composition in patients with angina at rest and angina of effort (functional classes 3-4). In addition to a drop in total cholesterol and triglycerides, cholesterol in low and very-low-density lipoproteins fell abruptly, while high-density-lipoprotein cholesterol, on the contrary, increased considerably. Clinical improvement of the patients was also recorded.

Cardiovascular risk in patients with treated familial hypercholesterolaemia and patients with severe hypertriglyceridaemia

A study was performed to determine the morbidity and mortality from ischaemic heart disease (IHD) in patients with heterozygous familial hypercholesterolaemia (FH) and severe hypertriglyceridaemia (pretreatment plasma triglyceride greater than 5 mmol/l). Twenty-nine (38%) of 76 patients with FH and 8(44%) of 18 patients with hypertriglyceridaemia had evidence of IHD. Over a mean follow-up period of 5.5 years, 2 patients with hypertriglyceridaemia died but there were no deaths in patients with FH. This contrasts with earlier reports which showed a high mortality in FH patients. The lower mortality may be due to improved treatment and consequent lower levels of cholesterol.

[Effect of partial ileoshunting on hyperlipoproteinemia in patients with atherosclerosis]

In 57 atherosclerotic patients with concomitant hyperlipoproteinemia operations of partial ileoshunts were performed consisting in shunting the distal third of the small intestine. The follow-up observation was up to 6 years. A persistent decrease of the elevated level of lipids and cholesterol of atherogenic LDL and VLDL was noted as well as a considerable and stable increase of the level of cholesterol of antiatherogenic very high density lipoproteins and a lower atherogeneity coefficient. It facilitates stabilization and regression of atherosclerosis.

Low density lipoprotein metabolism in familial combined hyperlipidemia. Mechanism of the multiple lipoprotein phenotypic expression

Plasma low density lipoprotein (LDL) kinetics and their relation to plasma very low density lipoprotein (VLDL) and LDL composition were determined in patients with familial combined hyperlipidemia (FCHL) of varying lipoprotein phenotypes. In both Type II and IV subjects, LDL apolipoprotein B (apo B) synthesis was greater than normal. In Type IV, the VLDL triglyceride/apo B ratio was normal and almost all of the LDL apo B was derived from VLDL. LDL cholesterol/apo B ratio was diminished and LDL apo B fractional catabolic rate (FCR) was sufficiently increased to prevent a rise in plasma LDL concentration. In Type II, VLDL triglyceride/apo B was reduced and 14% to 50% of the LDL was formed by direct synthesis. LDL cholesterol/apo B was normal and LDL apo B FCR was lower than in Type IV subjects. In four patients whose plasma lipid levels became normal with carbohydrate restriction and intake of a fibric acid derivative, plasma VLDL and LDL composition and LDL kinetic measurements remained unchanged. By contrast, VLDL triglyceride-apo B decreased and direct LDL synthesis increased in four patients whose phenotype changed to Type IIa. LDL cholesterol/apo B also increased and LDL FCR declined. Among patients with FCHL, significant correlations between VLDL triglyceride/apo B, LDL apo B derived by direct synthesis, LDL cholesterol/apo B, and LDL apo B FCR were found. Thus, increased apo B synthesis is a characteristic feature of FCHL. The phenotypic expression is determined by the availability of triglyceride for hepatic coupling to apo B which could influence the source, composition, and removal rate of circulating LDL. Despite normalization of their plasma lipid levels, some patients continued to show the compositional and kinetic features of FCHL.

Therapy for uremic hyperlipidemia

Once the decision is made to treat hyperlipidemia in a dialysis patient, several options for therapy are available. This review organizes a therapeutic approach into manipulations primarily by the patient (achievement of ideal body weight, exercise, various diets) and manipulations primarily by the physician. Dialytic options include the composition of the dialysate (buffer, glucose), peritoneal dialysis, hemodialysis and hemofiltration. The roles of dialysis efficiency and heparin are discussed in this context. Medicinal manipulations include drugs to avoid (beta adrenergic blockers, androgens, estrogens, glucocorticoids, ethyl alcohol, diuretics) and specific therapeutic agents (activated charcoal, nicotinic acid, clofibrate, L-carnitine).

Clofibrate, caloric restriction, supersaturation of bile, and cholesterol crystals

Lipid composition, cholesterol saturation, and cholesterol crystal formation of gallbladder bile were studied in seven type-IV hyperlipoproteinemic subjects who did not have gallstones. Thereafter, biliary cholesterol solubilization was overloaded, first by clofibrate and then by caloric restriction treatment. Initially increased cholesterol saturation was still increased by both clofibrate and caloric restriction treatment, but none of the subjects developed cholesterol crystals in bile, indicating that they had a mechanism to maintain cholesterol in solution in the bile despite remarkable supersaturation. This suggests that the patients who are at risk of developing gallstones can be better selected by cholesterol crystal analysis of bile samples than by analysis of lipid composition of bile.

Parenteral nutrition in a patient with familial Type IV hypertriglyceridemia: a dilemma

Patients with a Type IV familial hypertriglyceridemia should never receive intravenous fat emulsions. In addition, the amount of carbohydrate that can be given is limited. A 33-year-old white female, with Type IV hypertriglyceridemia, began receiving a parenteral nutrition regimen that included fat. A series of lipid studies was planned, coordinated with fat emulsion and glucose administration. The patient had persistently elevated basal triglyceride levels (greater than 250 mg/dL), which rose in response to both fat and carbohydrate administration. Serum cholesterol levels remained within the normal range. The disease was once known as "carbohydrate-induced lipemia" because of the dramatic rise in serum triglyceride following high carbohydrate diets. We suggest that serum triglyceride levels be monitored in all patients receiving parenteral nutrition; when such a patient is identified, fat emulsion should not be given and dextrose should be used in the smallest possible amounts to achieve a positive nitrogen balance.

Fenofibrate and human liver. Lack of proliferation of peroxisomes

In rodents fenofibrate shares with other triglyceride-lowering agents the potential to increase the liver peroxisome population. It was therefore of interest to look for this effect in hyperlipoproteinemic patients receiving this drug. Light and electron microscopy of liver biopsies from a group of 10 patients treated with fenofibrate and from another group of 15 receiving diet only, show no morphological difference between both groups. In contrast with the rodent data the morphometric study reveals no significant changes in the number (fenofibrate group: 7.96 10(10) cm-3; group receiving diet alone: 8.41 10(10) peroxisomes/cm3 of liver tissue) or in the size (fenofibrate group: Diameter = 0.53 +/- 0.07 micrometer--group receiving diet alone: 0.50 +/- 0.06) of peroxisomes. The difference between our results and those obtained consistently in rodents may be due to the relatively low dose in man and/or a species-dependent difference in enzyme content of liver peroxisomes, itself related to an apparent difference in the way in which lipids are handled.

Variations in lipids and proteins of lipoproteins by fenofibrate in some hyperlipoproteinaemic states

A total of 28 hyperlipoproteinaemic patients (8 type IIA, 12 type IIB and 8 type IV) were studied. Each patient was put on a 'prudent' isocaloric diet (50% carbohydrate, 30% fat, 20% protein) following a 2-month period of wash-out. Fenofibrate (300 mg/day) was then given for 2 periods of 2 months, each separated by a 2-month period in which only the dietary treatment was continued. Fenofibrate induced a significantly beneficial effect on the abnormal plasma levels of lipids and apolipoproteins A-I and B in all three phenotypes. Total cholesterol significantly decreased in type IIA and IIB; total triglycerides decreased significantly in all three types. HDL-C increased in all the patients but significantly only in those presenting types IIB and IV. ApoB significantly decreased in the 3 groups while apoA-I increased. The ratio apoA/apoB increased significantly in the three groups. Enzymatic parameters did not vary during the drug treatment. However, 6 patients (16%) dropped out because of gastro-intestinal side effects.

Chylomicronemia syndrome. Interaction of genetic and acquired hypertriglyceridemia

Chylomicrons accumulating in plasma obtained after an overnight fast are always abnormal and can be detected in association with triglyceride levels above 1000 mg per dl. The chylomicronemia syndrome is associated with marked hypertriglyceridemia (plasma triglyceride level above 2000 mg per dl), abdominal pain or pancreatitis, eruptive xanthomata, lipemia retinalis, dyspnea, mental aberrations, and other minor findings. The marked hypertriglyceridemia is usually due to the interaction of a common familial form of hypertriglyceridemia and a common acquired form of hypertriglyceridemia secondary to another disease, drug, or alcohol. Rarely, genetic abnormalities in lipoprotein lipase are the cause of the marked hypertriglyceridemia. Therapy that successfully lowers plasma triglyceride levels is associated with clearing of the symptoms and signs of the chylomicronemia syndrome and prevention of its recurrence.

[Disorders of glucose metabolism and manifestation of diabetes during treatment of endogenous hypertriglyceridemias (author's transl)]

Disturbances of glucose metabolism are frequent concomitant findings with hypertriglyceridemias (HTG). Whether the manifestation of diabetes mellitus is favored by it is, however, unknown. In an observation study disturbed glucose metabolism was present in 47 of 91 cases of HTG, without drug therapy of diabetes being carried out. The study shows that glucose metabolism disorders in HTG annually regress in about 3% of cases and about 0.6 to 0.7% of the cases require drug treatment. Since retrospective and prospective analyses show that development of glucose tolerance disorders is closely related to changes in triglyceride concentrations, HTG must be considered as factors favoring diabetes mellitus.

Effects of portacaval shunt on the genetically obese Zucker Rat

Male adult obese (fa/fa) Zucker rats with high hypertriglyceridemia and hyperinsulinemia, and mild hypercholesterolemia were submitted to a portacaval shunt in order to examine the effects of this shunt on blood lipids and lipid synthesis. Sham-operated pair-fed obese (fa/fa) Zucker rats, obese (fa/fa) Zucker rats fed ad libitum, and lean (Fa/?) littermates fed ad libitum served as controls. In fa/fa rats 3 wk after portacaval shunt, fasting serum values of triacylglycerol (-70%) and cholesterol (-43%) were lower and plasma total glucagon was higher (+68%) than in pair-fed sham-operated fa/fa controls. In the same rats 4 wk after portacaval shunt and while fed ad libitum, serum protein was reduced by 22%, plasma pancreatic glucagon was 100% higher, and the hyperinsulinema was not modified. At that time, the wet weight of the liver and its total content in DNA, RNA, protein, and glycogen was decreased by 43%, 22%, 34%, 39%, and 60%, respectively. The in vivo incorporation of 3H2O into liver fatty acids was 76% lower and that into liver cholesterol eas 43% lower, per total organ, while the labeling of glyceride fatty acids was not modified in epididymal adipose tissue when compared with pair-fed fa/fa Zucker rats. In conclusion, portacaval shunting lowered blood triacylglycerol and cholesterol levels in fa/fa rats, and this was due, at least partially, to reduction in hepatic lipogenesis and cholesterologenesis.

Fibrinogen catabolism in patients with type II and type IV hyperlipidemia. Effect of dietary and clofibrate treatment on laboratory findings

Fibrinogen catabolism was studied by plasma fibrinogen chromatography and other methods in 99 subjects with hyperlipoproteinemia Types IIa, IIb, and IV, and in 24 control subjects with normal blood lipid values. Subjects with either a history of thromboembolic vascular disease or clinical evidence of atherosclerosis were excluded. Type II subjects (i.e., the combined group of Type IIa and IIb subjects) showed an elevation of plasma high molecular weight fibrinogen complexes, which is indicative of enhanced fibrin formation. They also showed an elevation of fibrinogen-first-derivative, which is indicative of fibrinogenolysis and increased plasma euglobulin activity. Subjects with Type IV hyperlipoproteinemia showed similar findings to those of Type II except that high molecular weight fibrinogen complex concentration was normal. Subsequently, 36 patients received a fat-controlled, low cholesterol diet and were studied in a blind, random, crossover study of dietary vs clofibrate treatment. Although total cholesterol and triglyceride levels fell significantly during the treatment periods, chromatographic findings of abnormal plasma fibrinogen remained unchanged.

A-IMilano apoprotein. Decreased high density lipoprotein cholesterol levels with significant lipoprotein modifications and without clinical atherosclerosis in an Italian family

Significant hypertriglyceridemia with a very marked decrease of high density lipoproteins (HDL)-cholesterol levels (7-14 mg/dl) was detected in three members (father, son, and daughter) of an Italian family. The three affected individuals did not show any clinical signs of atherosclerosis, nor was the atherosclerotic disease significantly present in the family. Lipoprotein lipase and lecithin:cholesterol acyltransferase activites were normal or slightly reduced. Morphological and compositional studies of HDL in the subjects showed a significant enlargement of the lipoprotein particles (approximately 120 vs. approximately 94 A for control HDL) and a concomitant increase in the triglyceride content. Analytical isoelectric focusing of HDL apoproteins provided evidence for multiple isoproteins in the apoprotein(apo)-A-I range, with nine different bands being detected instead of the usual four bands observed in normal subjects. Two-dimensional immunoelectrophoresis against apo-A antiserum indicated a clear reduction of apo-A in the alpha electrophoretic region, with splitting of the protein "peak." The observation in otherwise clinically healthy subjects of hypertriglyceridemia, reduced HDL-cholesterol, and marked apoprotein abnormalities, without a significant incidence of atherosclerotic disease in the family suggests this is a new disease entity in the field of lipoprotein pathology, very probably related to an altered amino acid composition of the apo-A-I protein (see Weisgraber et al. 1980. J. Clin. Invest. 66: 901-907).

Type IV hyperlipoproteinemia: effects of a caloric restricted type IV diet versus physical training plus isocaloric type IV diet

Serum lipids, plasma insulin and glucagon, aerobic capacity, and body composition were examined in middle-aged men (X age = 44.2 years) with type IV hyperlipoproteinemia to determine the relative effectiveness of a caloric restricted type IV hyperlipoproteinemia diet (group A) versus physical training plus an isocaloric type IV diet (group B). After 9 weeks of the above interventions, reductions (P less than 0.01) in mean cholesterol levels from 213 to 186 (12% change) and from 205 to 185 mg/dl (9% change), and in triglyceride levels from 332 to 211 (29% change) and from 263 to 138 mg/dl (42% change) were found for groups A and B, respectively. A small reduction in mean fasting insulin level was found only in group B; this reduction appeared inversely associated with increases in aerobic capacity in group B (r = -0.66). Both interventions were without effect on fasting glucagon levels. The physical training program prescribed resulted in a 12% increase in aerobic capacity (group B). Significant mean body weight reductions of 7.7 lb (P less than 0.01) and 2.9 lb (P less than 0.01) were seen for groups A and B, respectively; these absolute body weight reductions differed significantly (P less than 0.05) between groups. Both groups significantly lost body fatness (P less than 0.01). These reductions in body weight and body fatness appeared independent of changes in lipid levels. These results demonstrate that both interventions reduce serum lipids in men with type IV hyperlipoproteinemia but that physical training plus an isocaloric type IV diet may be the more advantageous of the two regimens, since a greater percentage decrease and a more sustained reduction in serum triglyceride levels, and a greater reduction of fasting hyperinsulinemia were observed in group B.

Pronounced lipoprotein lipid reduction obtained by combined lipid-lowering treatment in patients with atherosclerotic disease

The feasibility of reducing serum lipoprotein levels in patients with atherosclerotic disease by combining diet, clofibrate and nicotinic acid (niceritrol) has been investigated. An additive lipid-lowering effect of diet and the two drugs was demonstrated. It was possible to reduce the serum triglycerides (TG) in hypertriglyceridaemic patients by 50-60%. This corresponded to a reduction of very low density lipoprotein (VLDL) TG by 73 and 66% in patients with hyperlipoproteinaemia (HLP) type IIB and IV, respectively. In normotriglyceridaemic patients the serum TG concentration decreased by 30-40%. The serum cholesterol (Chol) concentration was reduced by 33% and the low density lipoprotein (LDL) Chol by 37% in HLP type IIA and IIB. The LDL Chol decreased by 32% in normolipoproteinaemic patients and by 21% in HLP type IV. The mean value for serum cholesterol after therapy was in all groups close to 200 mg/100 ml. In hypertriglyceridaemic patients high density lipoprotein (HDL) Chol increased by 18%. Clofibrate and niceritrol differed with regard to the effect on serum lipoprotein concentrations as well as on other metabolic parameters. Niceritrol was significantly more effective than clofibrate in lowering LDL Chol and in increasing HDL Chol. Niceritrol treatment significantly reduced the Chol/TG ratio in VLDL while no such effect was seen during clofibrate administration. The two drugs also showed significantly different effects on the fractional removal rate (K2) of triglyceride-rich lipoproteins as measured by the intravenous fat tolerance test (IVFTT). The K2 was significantly increased by clofibrate but was not affected by niceritrol treatment. The two drugs differed also with regard to the effects on serum uric acid concentration and the liver function tests. The plasma fibrinogen levels and the erythrocyte sedimentation rates were reduced during treatment with both niceritrol and clofibrate. The present study demonstrates that it is possible to obtain substantial reductions of serum lipoprotein concentrations by combining lipid-lowering diet, clofibrate and niceritrol treatment. There was an additive lipid-lowering effect of this treatment and the combination of the two drugs seemed beneficial in regard to certain possible side effects. The impact of a lipid reduction within this range on cardiovascular morbidity and mortality remains to be evaluated.