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Severe Hypertriglyceridemia

Chloe de Crecy

Background

  • Elevated triglycerides (TG) on a fasting lipid panel
    • Normal: <150 mg/dL
    • Moderate HTG: 150-499 mg/dL
    • Moderate to severe HTG: 500-999 mg/dL
    • Severe HTG: >1000 mg/dL
  • Nearly all pts with severe HTG have a genetic predisposition + additional risk factor (e.g. DM, alcohol abuse, oral estrogen, hypothyroidism, nephrotic syndrome, propofol, ART)
  • Risks of hypertriglyceridemia: pancreatitis (requires serum TG >500 mg/dL), ASCVD
  • Signs: xanthomas, hepatosplenomegaly, lipemia retinalis, milky appearance of plasma
  • Sxs: short-term memory loss, abdominal pain, flushing with ETOH

Evaluation

  • Lipid panel: usual outpt screening, acute pancreatitis, cutaneous xanthomas, familial HTG, monitoring HTG treatment
  • Note: Na, glucose, amylase, LDL readings can be affected by HTG
  • Consider sending A1c, Cr, TSH
  • Assess medication list for secondary causes

Management

  • HTG induced pancreatitis
    • If pt has hypocalcemia, lactic acidosis, or multi-organ dysfunction
      • Initiate plasmapheresis and monitor serum TG after each cycle until <500
      • Severe dietary fat restriction (<5%) until TG <1000
    • If none of the above and pt is hyperglycemic
      • Start insulin gtt, IVF, monitor q1h BG and q12h TG
      • Discontinue insulin when serum TG <500
      • Severe dietary fat restriction (<5%) until TG <1000
    • If none of the above and pt is euglycemic
      • Start insulin gtt + dextrose, Monitor q12h TG until <500
      • Severe dietary fat restriction (<5%) until TG <1000
  • Long-term Management (once TG <1000, otherwise decreased efficacy)
    • Pharmacologic: fibrates (most commonly fenofibrate), statins, niacin, omega-3 fatty acids
    • Nonpharmacologic: discontinue ETOH use, dietary fat and sugar restriction (target fat intake at <10% of calorie intake), exercise