Severe Hypertriglyceridemia (HTG)¶
Chloe de Crecy
Background¶
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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
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Nearly all patients with severe HTG have a genetic predisposition and an additional factor known to raise serum TGs (e.g. diabetes, alcohol abuse, oral estrogen therapy, hypothyroidism, nephrotic syndrome, propofol, ART, pregnancy)
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Risks of hypertriglyceridemia: pancreatitis (can occur if serum TG >500 mg/dL), ASCVD
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Signs: xanthomas, hepatosplenomegaly, lipemia retinalis, milky appearance of plasma
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Symptoms: short-term memory loss, abdominal pain, flushing with alcohol
Evaluation¶
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Order lipid panel for: usual outpatient screening, acute pancreatitis, cutaneous xanthomas, family members with familial HTG, monitoring HTG treatment
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Note: Sodium, glucose, amylase, LDL readings can be affected by HTG
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Consider sending A1c, Cr, TSH
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Assess medication list for secondary causes
Management¶
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HTG induced pancreatitis
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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
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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
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If none of the above and patient is euglycemic
- Monitor q12h TG until <500
- Severe dietary fat restriction (<5%) until TG <1000
- Consider initiation of insulin gtt as well (regardless of BG level) as insulin will help metabolize TG particles
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Long-term Management (once TG <1000, otherwise decreased efficacy)
- Pharmacologic: fibrates (most commonly fenofibrate), statins, niacin, omega-3 fatty acids
- Nonpharmacologic: discontinue alcohol use, dietary fat and sugar restriction (target fat intake at <10% of calorie intake), exercise