Management of hypertriglyceridemia

پنجمين كنگره بين المللي پيشگيري از بيماريهاي قلب و عروق

7 الي 9 مهر 1395، شيراز - ايران

Presentation Type: Speech

The causes of hypertriglyceridemia(HTG) may be categorized into genetically based disorders (primary disorders) and secondary disorders due to other diseases. The only genetically well characterized kinds of HTG are lipoprotein lipase (LPL) deficiency and apolipoprotein (Apo) C-II deficiency, which usually present in infancy as chylomicronemia syndromes causing HTG at early childhood age. In adults, HTG usually presents with very high fasting levels of chylomicrons, VLDL, and remnants . This condition is probably plurigenetic with a strong environmental and lifestyle impact on its manifestation. Occasionally, a patient with ApoE2/E2 homozygosis (dysbetalipoproteinemia, type III hyperlipoproteinemia) will develop HTG.
There is a large number of secondary causes of HTG. Among these, obesity, untreated diabetes mellitus, alcohol, pregnancy, and different drugs are probably the most common. Several of the secondary causes are associated with abnormalities of insulin responsiveness.
Severe hypertriglyceridemia (TG>500-1000) is well known to be associated with acute pancreatitis. Concerning the role of triglycerides (TG) in promoting cardiovascular disease, there has been controversial discussions for more than 60 years ,and currently it is not considered as an important factor. The role of Severe HTG in causing acute pancreatitis, however, is commonly accepted. According to the literature, Severe HTG is the most common cause for acute pancreatitis after gallstones and alcohol. Severe HTG is reported to account for up to 10% of all acute pancreatitis episodes . Some studies on gestational pancreatitis even report Sever HTG as the underlying etiology in more than half of all cases .There is even some evidence that hypertriglyceridemic pancreatitis is associated with a higher severity and a higher complication rate .The management of HTG depends on the level of TG. Mild and moderate hypertriglyceridemia (triglycerides of 150–500 mg/dl) must be considered in context of cardiovascular risk and the main goal should be maintaining appropriate LDL levels by life style modifications and statins. In severe hypertriglyceridemia ,the main target is rapid treatment of HTG to prevent pancreatitis. The initial treatment should be removing or treating any secondary causes, lifestyle change and drug therapy. In patients with severe HTG, a fibrate should be used as a first-line agent. The general treatment regimen for SHTG includes dietary restrictions and lipid-lowering drug treatment such as the use of medium-chain triglycerides (MCT), fibrates, omega-3-fatty acids , and nicotinic acid. Yet, drugs of first choice, such as fibrates, do not offer fast onset of action, while immediately acting drugs like omega-3-FA and MCT may not be powerful enough to lower excessively elevated TG levels rapidly. Since patients with excessively elevated TG levels are in urgent need of a fast and effective lowering of their TG levels in order to prevent a severe pancreatitis episode, further measures must be taken. Immediate apheretic treatment might thus be considered as an option in order to rapidly lower excessively elevated TG levels and prevent or attenuate acute pancreatitis in these patients.

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