Hypertriglyceridemia: Difference between revisions
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***[[DM]], obesity, [[EtOH]], estrogen therapy | ***[[DM]], obesity, [[EtOH]], estrogen therapy | ||
***[[Hypothyroidism]], ESRD, nephrotic syndrome, [[HIV]], anti-HIV meds | ***[[Hypothyroidism]], ESRD, nephrotic syndrome, [[HIV]], anti-HIV meds | ||
*TG levels > | *TG levels > 2000mg/dL almost always have both secondary and genetic form<ref>Yuan et al. Hypertriglyceridemia: its etiology, effects and treatment. CMAJ 2007;176:1113-1120.</ref> | ||
[[File:hypertriglyceridemia_green_top.jpg|thumbnail]] | [[File:hypertriglyceridemia_green_top.jpg|thumbnail]] | ||
*May present with normal serum lipase levels | *May present with normal serum lipase levels | ||
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*Evidence for management based on case series and reports<ref>Santana YR et al. Treatment of severe hypertriglyceridemia with continuous insulin infusion. Case Reports in Critical Care. June 2011.</ref><ref>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.</ref> | *Evidence for management based on case series and reports<ref>Santana YR et al. Treatment of severe hypertriglyceridemia with continuous insulin infusion. Case Reports in Critical Care. June 2011.</ref><ref>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.</ref> | ||
*[[Insulin]] drip - most dramatic and rapid intervention, with reduction within 24 hrs | *[[Insulin]] drip - most dramatic and rapid intervention, with reduction within 24 hrs | ||
**5-10 units/hr with or without dextrose infusion to maintain BSs ~ | **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 | **May require higher dosages for diabetics, 0.1–0.3 U/kg/hr | ||
**Titrate to BS | **Titrate to BS 140–180mg/dL<ref>Schaefer EW. Management of Severe Hypertriglyceridemia in the Hospital: A Review. Journal of Hospital Medicine Vol 7|No 5|May/June 2012.</ref> | ||
*Treat concurrent hypothryoidism if present | *Treat concurrent hypothryoidism if present | ||
*Niacin | *Niacin 500mg qd | ||
*Gemfibrozil or fenofibrate | *Gemfibrozil or fenofibrate | ||
*Max dose statin, 81 mg ASA | *Max dose statin, 81 mg ASA | ||
*Heparin q8 SC, effect short-lived | *Heparin q8 SC, effect short-lived | ||
*NPO initially | *NPO initially | ||
*May advance diet starting at TG level < | *May advance diet starting at TG level < 1000mg/dL with resolution of abdominal pain/pancreatitis symptoms | ||
**No fat diet | **No fat diet | ||
**Low calorie diet | **Low calorie diet | ||
*Follow TG levels, goal < 500- | *Follow TG levels, goal < 500-1000mg/dL by discharge | ||
===Plasma Exchange=== | ===Plasma Exchange=== | ||
Revision as of 10:41, 19 July 2016
Background
- ~5% of acute pancreatitis caused by high triglycerides[1]
- Etiologies
- Familial hypertriglyceridemia, autosomal dominant with variable penetrance
- Secondary forms
- DM, obesity, EtOH, estrogen therapy
- Hypothyroidism, ESRD, nephrotic syndrome, HIV, anti-HIV meds
- TG levels > 2000mg/dL almost always have both secondary and genetic form[2]
- May present with normal serum lipase levels
Management of Pancreatitis
- Evidence for management based on case series and reports[3][4]
- 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[5]
- Treat concurrent hypothryoidism if present
- Niacin 500mg qd
- Gemfibrozil or fenofibrate
- Max dose statin, 81 mg 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
- ↑ Yadav D, Pitchumoni CS. Issues in hyperlipidemic pancreatitis. J Clin Gastroenterology 2003;36:54-62.
- ↑ Yuan et al. Hypertriglyceridemia: its etiology, effects and treatment. CMAJ 2007;176:1113-1120.
- ↑ Santana YR et al. Treatment of severe hypertriglyceridemia with continuous insulin infusion. Case Reports in Critical Care. June 2011.
- ↑ 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.
- ↑ Schaefer EW. Management of Severe Hypertriglyceridemia in the Hospital: A Review. Journal of Hospital Medicine Vol 7|No 5|May/June 2012.