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Severe Hypertriglyceridemia (HTG)

Chloe de Crecy


  • 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 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)

  • Risks of hypertriglyceridemia: pancreatitis (can occur if serum TG >500 mg/dL), ASCVD

  • Signs: xanthomas, hepatosplenomegaly, lipemia retinalis, milky appearance of plasma

  • Symptoms: short-term memory loss, abdominal pain, flushing with alcohol


  • Order lipid panel for: usual outpatient screening, acute pancreatitis, cutaneous xanthomas, family members with familial HTG, monitoring HTG treatment

  • Note: Sodium, glucose, amylase, LDL readings can be affected by HTG

  • Consider sending A1c, Cr, TSH

  • Assess medication list for secondary causes


  • 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 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
  • 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

Last update: 2022-06-20 11:59:42