Long-term follow-up of patients with acute hypertriglyceridemia-induced pancreatitis

Anthropometric Indicators in Hypertriglyceridemia Discrimination: Application as Screening Tools in Older Adults

Background and Purpose: The use of anthropometric indicators as discriminators of hypertriglyceridemia has not been thoroughly investigated. The purpose of this article is to comparatively evaluate anthropometric indicators as discriminators of hypertriglyceridemia in older Brazilian adults. Methods: This cross-sectional study derived from population-based epidemiological research involving 316 community-dwelling older adults (60–105 years old). Results: Except for the conicity index and the body adiposity index in the group of women, all other anthropometric indicators (i.e., body mass index, waist and calf circumferences, triceps skinfold thickness, and waist–stature and waist–hip ratios) were sufficient to identify hypertriglyceridemia in the population. Conclusions: We endorse anthropometric indicators for use in screening for hypertriglyceridemia in older Brazilian adults.

Coagulopathy and the prognostic potential of D-dimer in hyperlipidemia-induced acute pancreatitis

BACKGROUND

Coagulopathy and its association with disease severity in hyperlipidemia (HL)- and non-hyperlipidemia (NHL)-induced acute pancreatitis (AP) are not clear. The present study was to evaluate the relationship between coagulation homeostasis and AP.

METHODS

This study included 106 AP patients admitted to our hospital between October 2011 and January 2013. Stratified by disease severity, the patients were divided into two groups: a mild AP (MAP) group (n=69); and a moderately severe AP (MSAP) group (n=37). Based on disease etiology, there were 31 HL-induced AP (HLP) cases and 75 NHL-induced AP (NHLP) cases. The HLP and NHLP groups were compared for parameters of coagulation homeostasis, lipid metabolism, and disease severity. Correlations between disease severity and levels of D-dimer and protein C were investigated, and the prognostic potential of D-dimer was evaluated.

RESULTS

Compared with MAP patients, MSAP patients showed higher levels of D-dimer and lower levels of protein C. HLP patients had higher protein C levels than NHLP patients. Both D-dimer and protein C levels were significantly associated with the disease severity, not the disease etiology. D-dimer levels correlated positively with low density lipoprotein cholesterol levels and performed well as a sensitive and specific predictor of disease severity in AP patients, especially in HLP patients.

CONCLUSIONS

The coagulation homeostasis is different between HLP and NHLP patients, and HL may be a contributing factor for thrombosis and fibrinolysis in HLP. D-dimer may be a robust marker of disease severity in HLP.

Different Clinical Presentations of Hyperlipidemic Acute Pancreatitis: A Retrospective Study

OBJECTIVES

The goal of this study was to summarize the clinical features of hyperlipidemic acute pancreatitis (HLAP), and help clinicians understand the characteristic presentations of HLAP.

METHODS

From July 2009 to June 2013, 1073 cases of acute pancreatitis were retrospectively assessed. The clinical characteristics of HLAP and non-HLAP were statistically analyzed.

RESULTS

The etiologic ratio of HLAP in acute pancreatitis rose from 13% in 2009 to 25.6% in 2013. Diabetes mellitus, fatty liver, and acute pancreatitis recurrence were positively correlated with HLAP, and female sex, age (>60 years), and alkaline phosphatase level were negatively correlated with HLAP. The diagnostic accuracy of amylase in HLAP was only 40.38%, compared with lipase (91.83%). Different cutoff points of serum triglyceride on day 1 (5.33 mmol/L), day 2 (2.77 mmol/L), and day 3 (2.18 mmol/L) could be used to obtain an accurate diagnosis of HLAP. Higher incidences of acute peripancreatic fluid collection, renal failure, and severe acute pancreatitis were also observed in patients with HLAP.

CONCLUSIONS

Different clinical presentations of HLAP should be applied to be distinguished from non-HLAP in the clinic.

Elevated serum triglycerides are independently associated with persistent organ failure in acute pancreatitis

OBJECTIVES

Hypertriglyceridemia (HTG) represents a major health problem with prevalence exceeding 30% in the U.S. The present study aims to assess the effect of elevated serum triglyceride (TG) levels on the severity of acute pancreatitis (AP).

METHODS

Prospectively enrolled AP patients were categorized into normal, mild, moderate, and severe/very severe categories based on their TG levels and compared in respect to demographics, comorbidities, and clinical outcomes. Multivariate analysis determined whether elevated TG levels were independently associated with persistent organ failure.

RESULTS

Two hundred and one out of 400 AP patients had serum TGs measured within 72 h of presentation, of which 115 had normal TG levels and 86 HTG (20 mild, 41 moderate, and 25 severe/very severe). Patients with HTG were of younger age (44 vs. 52 years), predominantly male (65% vs. 45%), obese (57% vs. 34%), diabetic (38% vs. 17%), and developed more frequently persistent organ failure (40% vs. 17%) compared with those with normal TGs (P<0.02). The rate of persistent organ failure increased proportionally with HTG severity grades (17% when normal TGs, 30% in mild, 39% in moderate, and 48% in severe/very severe HTG, Ptrend<0.001). On multivariate analysis controlling for age, gender, body mass index, diabetes, and alcohol etiology, moderate HTG (odds ratio (OR), 2.6; P=0.04) and severe/very severe HTG (OR, 4.9; P=0.009) were independently associated with persistent organ failure.

CONCLUSIONS

Elevated serum TGs in AP patients are independently and proportionally correlated with persistent organ failure regardless of etiology. TG-mediated lipotoxicity may be an attractive target to design novel interventions for severe AP.

Clinical Study of 224 Patients with Hypertriglyceridemia Pancreatitis

BACKGROUND

Hypertriglyceridemia (HTG) is the most common etiology of acute pancreatitis (AP) after alcohol and gallstone-induced disease. Elevation of serum triglyceride (TG) levels to ≥ 1000 mg/dl in a patient with AP strongly indicates HTG as the cause. The absolute risk of pancreatitis based on serum TG ≤ 1000 mg/dl has not been clearly defined. The aims of this study were to address the role of elevated TG levels between 500 and 1000 mg/dl in the clinical course of HTG pancreatitis (HTGP); and assess the relationship between the level of serum TG and disease severity.

METHODS

A total of 224 HTGP patients between 2007 and 2011 were divided into two subgroups. Totally, 122 patients in Group A had serum TG >1000 mg/dl; 102 patients in Group B had maximal TG levels between 500 and 1000 mg/dl accompanied by lactescent serum; 100 patients with biliary AP and 99 patients with alcoholic AP hospitalized during the study period were enrolled as controls. The clinical and biochemical data were analyzed.

RESULTS

The clinical presentation of HTG-induced pancreatitis was similar to other causes. Severe form of AP in Group A was higher than Group B (χ2 = 4.002, P = 0.045). The severity with HTGP was significantly higher as compared to biliary AP (χ2 = 33.533, P = 0.000) and alcoholic AP (χ2 = 7.179, P = 0.007). Systemic complications with HTGP were significantly higher than biliary AP (χ2 = 58.763, P = 0.000).

CONCLUSIONS

The study demonstrated that TG level ≥ 500 mg/dl should raise a high degree of suspicion, especially if no other etiology of AP is apparent. The severity of HTGP seems to correlate directly with TG level. HTGP seems be more severe than other causes of AP.

Antisense Inhibition of Apolipoprotein C-III in Patients with Hypertriglyceridemia

BACKGROUND

Apolipoprotein C-III (APOC3) is a key regulator of plasma triglyceride levels. Elevated triglyceride levels are associated with a risk of adverse cardiovascular events and pancreatitis. ISIS 304801 is a second-generation antisense inhibitor of APOC3 synthesis.

METHODS

We conducted a randomized, double-blind, placebo-controlled, dose-ranging, phase 2 study to evaluate ISIS 304801 in untreated patients with fasting triglyceride levels between 350 mg per deciliter (4.0 mmol per liter) and 2000 mg per deciliter (22.6 mmol per liter) (ISIS 304801 monotherapy cohort), as well as in patients receiving stable fibrate therapy who had fasting triglyceride levels between 225 mg per deciliter (2.5 mmol per liter) and 2000 mg per deciliter (ISIS 304801-fibrate cohort). Eligible patients were randomly assigned to receive either ISIS 304801, at doses ranging from 100 to 300 mg, or placebo, once weekly for 13 weeks. The primary outcome was the percentage change in APOC3 level from baseline.

RESULTS

A total of 57 patients were treated in the ISIS 304801 monotherapy cohort (41 received active agent, and 16 received placebo), and 28 patients were treated in the ISIS 304801-fibrate cohort (20 received active agent, and 8 received placebo). The mean (±SD) baseline triglyceride levels in the two cohorts were 581±291 mg per deciliter (6.6±3.3 mmol per liter) and 376±188 mg per deciliter (4.2±2.1 mmol per liter), respectively. Treatment with ISIS 304801 resulted in dose-dependent and prolonged decreases in plasma APOC3 levels when the drug was administered as a single agent (decreases of 40.0±32.0% in the 100-mg group, 63.8±22.3% in the 200-mg group, and 79.6±9.3% in the 300-mg group, vs. an increase of 4.2±41.7% in the placebo group) and when it was administered as an add-on to fibrates (decreases of 60.2±12.5% in the 200-mg group and 70.9±13.0% in the 300-mg group, vs. a decrease of 2.2±25.2% in the placebo group). Concordant reductions of 31.3 to 70.9% were observed in triglyceride levels. No safety concerns were identified in this short-term study.

CONCLUSIONS

We found that treatment with ISIS 304801 was associated with significant lowering of triglyceride levels, among patients with a broad range of baseline levels, through selective antisense inhibition of APOC3 synthesis. (Funded by Isis Pharmaceuticals; ClinicalTrials.gov number, NCT01529424.).

Primary hypertriglyceridemia in children and adolescents

Primary disorders of lipid metabolism causing hypertriglyceridemia (HyperTG) result from genetic defects in triglyceride synthesis and metabolism. With the exception of lipoprotein lipase deficiency, these primary HyperTG disorders usually present in adulthood. However, some are unmasked earlier by precipitating factors, such as obesity and insulin resistance, and can be diagnosed in adolescence. Physical findings may be present and can include eruptive, palmer, or tuberoeruptive xanthomas. Triglyceride levels are very high to severe and can occur in the absence or the presence of other lipid abnormalities. Each of the causes of HyperTG is associated with an increased risk to develop recurrent pancreatitis and some may increase the risk of premature cardiovascular disease. Adoption of a healthy lifestyle that includes a low-fat diet, optimizing body weight, smoking avoidance/cessation, and daily physical activity is the first line of therapy. Pharmacologic therapies are available and can be beneficial in select disorders. Here, we review the causes of primary HyperTG in children and adolescents, discuss their clinical presentation and associated complications including the risk of pancreatitis and premature cardiovascular disease, and conclude with management and novel therapies currently in development. The goal of this article is to provide a useful resource for clinicians who may encounter primary HyperTG in the pediatric population.

Medical nutrition therapy is the essential cornerstone for effective treatment of "refractory" severe hypertriglyceridemia regardless of pharmaceutical treatment: Evidence from a Lipid Management Program

BACKGROUND

Patients with refractory severe hypertriglyceridemia are at risk of pancreatitis and cardiovascular disease. The role of individualized nutrition therapy in these patients independent of pharmaceutical treatment has not been documented.

OBJECTIVE

To document the effect of nutrition intervention on severe hypertriglyceridemia regardless of medication status or prior nutrition counseling.

METHODS

Outcomes of new patients with triglycerides ≥ 500 mg/dL presenting to a Lipid Management Program over a 6-year period were tracked. Patients received comprehensive laboratory assessment, nutrition assessment, and initiation of an individualized diet intervention before seeing the lipidologist. Clinical and behavioral outcomes were recorded.

RESULTS

In all, 168 patients (117 men; mean age, 49.03 ± 11.22 years; body mass index, 32.61 ± 5.85 kg/m(2); 110 (65.5%) on lipid-lowering medications) returned for assessment of nutrition intervention. Triglycerides were reduced from median (interquartile range) 961.5 (611.5-1785.3) to 493.0 (337-736.3) mg/dL (P < .0001 for log transformation of triglycerides). There was no difference in median percentage reduction in triglycerides after nutrition intervention between those not on lipid-lowering medication, on a fibric acid derivative, on other lipid-lowering medication, or on a combination of lipid-lowering medications (P = .376) in a median (interquartile range) of 5 (3-7) weeks. Effect was independent of prior nutrition counseling (P = .260). Reported percentage fat in the diet at second visit correlated with log-transformed triglycerides achieved, independent of initial triglycerides level (r = 0.290; P = .001).

CONCLUSIONS

Individualized nutrition therapy results in changes in eating behavior and reductions in triglyceride levels in patients with refractory severe hypertriglyceridemia independent of lipid-lowering medication(s) and prior nutrition counseling.

Contemporary review of drug-induced pancreatitis: A different perspective

Although gallstone and alcohol use have been considered the most common causes of acute pancreatitis, hundreds of frequently prescribed medications are associated with this disease state. The true incidence is unknown since there are few population based studies available. The knowledge of drug induced acute pancreatitis is limited by the availability and the quality of the evidence as the majority of data is extrapolated from case reports. Establishing a definitive causal relationship between a drug and acute pancreatitis poses a challenge to clinicians. Several causative agent classification systems are often used to identify the suspected agents. They require regular updates since new drug induced acute pancreatitis cases are reported continuously. In addition, infrequently prescribed medications and herbal medications are often omitted. Furthermore, identification of drug induced acute pancreatitis with new medications often requires accumulation of post market case reports. The unrealistic expectation for a comprehensive list of medications and the multifactorial nature of acute pancreatitis call for a different approach. In this article, we review the potential mechanisms of drug induced acute pancreatitis and provide the perspective of deductive reasoning in order to allow clinicians to identify potential drug induced acute pancreatitis with limited data.

C-reactive protein: rethinking its role in evaluating the severity of hyperlipidemic acute pancreatitis

OBJECTIVES

The goal of this study is to evaluate the role of C-reactive protein (CRP) in predicting the severity of hyperlipidemic acute pancreatitis (HLAP) compared with non-HLAP (NHLAP).

METHODS

A total of 1073 episodes of acute pancreatitis between July 2009 and June 2013 were retrospectively studied. The clinical characteristics and laboratory data of HLAP and NHLAP were statistically analyzed on days 1, 2, 3, 4, and 6, especially the CRP level.

RESULTS

There was a significant difference in CRP levels between HLAP and NHLAP (P < 0.01) on days 1, 2, 3, 4, and 6. The cutoff value for CRP in HLAP should be greater than NHLAP to obtain an accurate prediction of severity. Higher serum CRP levels in HLAP cases were correlated with higher incidences of diabetes and fatty liver and lower incidences in women, elevated very-low-density lipoprotein levels, and lower high-density lipoprotein levels.

CONCLUSIONS

The significant difference in CRP cutoff values in predicting severity between patients with HLAP and NHLAP should be noted in the clinic.

Plasma exchange treatment for acute hyperlipidemic pancreatitis with falsely low levels of serum triglycerides - a case report

Hypertriglyceridemia is a well-recognized cause of acute pancreatitis. We present a patient with acute hypertriglyceridemic pancreatitis. At presentation serum triglycerides were severely elevated (104 mmol/l) and were decreasing the next day (11 mmol/l). However, based on increasing levels of serum lipase, worsening respiratory failure and evidently lipemic serum, we decided to perform plasma exchange, and patient's condition improved dramatically. Repeated laboratory test of the serum obtained before the first plasma exchange revealed that the actual value of serum triglycerides was 57 mmol/l. A clinically-driven decision is crucial when treating patients with hypertriglyceridemic acute pancreatitis as the serum triglyceride levels can be falsely low.

Current knowledge of hypertriglyceridemic pancreatitis

Severe hypertriglyceridemia (HTG) is a well established and the most common cause of acute pancreatitis (AP) after alcohol and gall stone disease. It is alleged to account for up to 10% of all pancreatitis episodes. Studies suggest that in patients with triglyceride (TG) levels>1000 mg/dL (>11.3 mmol/L), hypertriglyceridemia-induced acute pancreatitis (HTGP-AP) occurs in approximately 15-20% of all subjects referred to Lipid Clinics. Until now, there is no clear evidence which patients with severe HTG will develop pancreatitis and which will not. Underlying pathophysiological concepts include hydrolysis of TG by pancreatic lipase and excessive formation of free fatty acids with inflammatory changes and capillary injury. Additionally hyperviscosity and ischemia may play a decisive role. The clinical features of HTG-AP patients are supposed to be no different from patients with AP of other etiologies. Yet, there are well-conducted studies suggesting that HTG-AP is associated with a higher severity and complication rate. Therapeutic measurements in HTG-AP include dietary modifications, different antihyperlipidemic agents, insulin and/or heparin treatment. The beneficial use of plasmapheresis is repeatedly reported and suggested in many studies. Yet, due to the lack of randomized and controlled trials, it is currently unknown if plasmapheresis may improve morbidity and mortality in the clinical setting of HTG-AP. Since there are no commonly accepted clinical guidelines in the management of HTG-AP, there is a definite need for an international, multicenter approach to this important subject.

Factors affecting outcome in acute hypertriglyceridemic pancreatitis treated with plasma exchange: an observational cohort study

Objectives

The optimal therapy for hypertriglyceridemic acute pancreatitis, especially the role of plasma exchange (PE), is not entirely clear. The aim of our large, single-center, observational, cohort study was to analyze the factors affecting outcome in hypertriglyceridemic pancreatitis treated with PE.

Methods

We included 111 episodes of hypertriglyceridemic pancreatitis treated with PE, which occurred in 103 different patients. The Acute Physiology and Chronic Health Evaluation (APACHE) II score, triglycerides, delay to first PE, and PE treatment details were retrospectively obtained from the patients’ records. The main outcome measures were length of hospitalization and in-hospital mortality.

Results

The patients were 47±9 years old and the median APACHE II score at first PE was 4 (inter-quartile range (IQR) 2–7). There was a seasonal variation in the incidence of hypertriglyceridemic pancreatitis, and the recurrence rate was 1.6% per year. Triglycerides at presentation did not correlate with APACHE II or influence the outcome. The mean reduction in triglycerides during PE was 59% (from 44±31 to 18±15 mmol/l), which was twice the reduction observed during conservative treatment (27% daily). The median hospital stay was 16 days (IQR 10–24) and in-hospital mortality was 5%. The median delay to first PE was 35 hours (IQR 24–52), and there was no difference in mortality in the early and late PE groups (7% vs. 6%, p = 0.79). The group with citrate anticoagulation during PE had a significantly lower mortality than the group with heparin anticoagulation (1% vs. 11%, p = 0.04), and citrate was an independent predictor also in the multivariate model (p = 0.049).

Conclusions

PE effectively reduced serum triglycerides faster than could be expected with conservative treatment. The delay in PE therapy did not influence survival. We found that citrate anticoagulation during PE was associated with reduced mortality, which should be confirmed in a randomized study.

Analyzing and identifying risk factors for acute pancreatitis with different etiologies in pregnancy

OBJECTIVE

To identify the risk factors of acute pancreatitis (AP) associated with different etiologies, in pregnancy (APP).

METHODS

Forty-seven eligible patients were divided into two groups: biliary acute pancreatitis in pregnancy (BAPP, n = 31) and hypertriglyceridemic-induced pancreatitis in pregnancy (HAPP, n = 16). Multivariate analysis was utilized in identifying independent risk factors of BAPP and HAPP.

RESULTS

The independent risk factors of BAPP included gallbladder stones (OR, 3.924; p = 0.007) and high-fat diet in pregnancy (OR, 4.878; p = 0.001). Hypertriglyceridemia (OR, 3.667; p = 0.035) was the only independent risk factor for HAPP. Based on the severity of AP, no significant differences in adverse outcomes were found between BAPP and HAPP.

CONCLUSIONS

High-fat diet should be prohibited for gravida with biliary diseases. Compared to biliary tract stones, the study observed that gallstones were more likely to cause AP for pregnant women. Hypertriglyceridemic pregnant women were found to be more susceptible to AP.

Severe hypertriglyceridemia induced pancreatitis in pregnancy

Acute pancreatitis caused by severe gestational hypertriglyceridemia is a rare complication of pregnancy. Acute pancreatitis has been well associated with gallstone disease, alcoholism, or drug abuse but rarely seen in association with severe hypertriglyceridemia. Hypertriglyceridemia may occur in pregnancy due to normal physiological changes leading to abnormalities in lipid metabolism. We report a case of severe gestational hypertriglyceridemia that caused acute pancreatitis at full term and was successfully treated with postpartum therapeutic plasma exchange. Patient also developed several other complications related to her substantial hypertriglyceridemia including preeclampsia, chylous ascites, retinal detachment, pleural effusion, and chronic pericarditis. This patient had no previous family or personal history of lipid abnormality and had four successful prior pregnancies without developing gestational hypertriglyceridemia. Such a severe hypertriglyceridemia is usually seen in patients with familial chylomicronemia syndromes where hypertriglyceridemia is exacerbated by the pregnancy, leading to fatal complications such as acute pancreatitis.

Incidence and clinical features of hyperlipidemic acute pancreatitis from Guangdong, China: a retrospective multicenter study

OBJECTIVE

This study aimed to investigate the clinical features and incidence trends of hyperlipidemic acute pancreatitis (HLAP) of multicenter studies in Guangdong, China, for 15 years.

METHODS

The medical records of 1582 patients with acute pancreatitis who were admitted to 4 general hospitals of Guangdong from January 1990 to December 2005 were reviewed. The inpatient medical and radiologic records were reviewed to determine clinical features, severity, complications, mortality, and recurrence rate.

RESULTS

A total of 7.8% (123/1582) patients met the HLAP criteria. Incidence of HLAP was approximately 2.6 times increased during 15 years (3.4% in 1990-1994, 5.9% in 1995-1999, and 8.9% in 2000-2005, respectively) and ranged from 3.3% to 15.5% in 4 hospitals across Guangdong. A history of diabetes was present in 31.7% and alcohol use in 18.7%. The mean (SD) triglyceride levels were 13.6 (7.2) mmol/L. Amylase was elevated higher than normal in 81.2% but only 2 times normal in 17.1% and 3 times normal in 37.6%. The frequency of severe acute pancreatitis, organ dysfunction, rate of recurrence, and mortality of HLAP was significantly higher than biliary-induced pancreatitis.

CONCLUSIONS

The incidence of HLAP had significantly increased during the past 15 years with a clear geographic variation and remarkable severity and recurrent trend.

Familial chylomicronemia syndrome related chronic pancreatitis: a single-center study

BACKGROUND

Hypertriglyceridemia induces acute recurrent pancreatitis, but its role in the etiology of chronic pancreatitis (CP) is controversial. This study aimed to evaluate the clinical, laboratory and radiological findings of 7 patients with CP due to type 1 hyperlipidemia compared to CP patients with other or undefined etiological factors.

METHODS

We retrospectively analyzed the clinical, laboratory and radiological findings of 7 CP patients with type 1 hyperlipidemia compared to CP patients without hypertriglyceridemia. These 7 patients had multiple episodes of acute pancreatitis and had features of CP on abdominal CT, endoscopic retrograde cholangiopancreatography and/or endoscopic ultrasonography.

RESULTS

All CP patients were classified into two groups: a group with type 1 hyperlipidemia (n=7) and a group with other etiologies (n=58). The mean triglyceride level was 2323+/-894 mg/dL in the first group. Age at the diagnosis of CP in the first group was significantly younger than that in the second group (16.5+/-5.9 vs 48.3+/-13.5, P<0.001). The number of episodes of acute pancreatitis in the first group was significantly higher than that in the second group (15.0+/-6.8 vs 4.0+/-4.6, P=0.011). The number of splenic vein thrombosis in the first group was significantly higher than that in the second group (4/7 vs 9/58, P=0.025). Logistic regression analysis found that younger age was an independent predictor of CP due to hypertriglyceridemia (r=0.418, P=0.000).

CONCLUSIONS

Type 1 hyperlipidemia appears to be an etiological factor even for a minority of patients with CP. It manifests at a younger age, and the course of the disease might be severe.

Tamoxifen-induced acute pancreatitis - a case report

Tamoxifen is a selective estrogen receptor modulator used for the treatment of oestrogen/progesterone receptor positive breast cancer. It has antagonistic or agonistic activity depending on the tissue location. Generally it causes mild and reversible side effects, however more serious ones including cardiovascular and thromboembolic adverse events, uterine cancer or acute pancreatitis can also occur. Tamoxifen, like oestrogens, increases the plasma level of TG and liver secretion of VLDL. Moreover, it inhibits the key enzymes of triglyceride metabolism. In this report we present a case of a 55-year-old woman with a history of a poorly controlled hypertriglyceridaemia diagnosed with breast cancer. She was treated with surgery and adjuvant chemotherapy, radiotherapy and hormonotherapy with tamoxifen. About three months after hormonal treatment, her triglyceride level increased. Five months later she developed an acute necrotic pancreatitis that required hospitalization. Her serum samples on admission were highly lipemic. An abdominal ultrasound showed no evidence of gallstones or dilation of the bile ducts. There was no history of alcohol abuse or abdominal trauma. Tamoxifen was suspected as a trigger factor for pancreatitis. After the drug withdrawal and administration of the conservative management the patient's medical condition improved. Due to a postmenopausal status of the patient and no harmful effect on serum lipids, an adjuvant hormonotherapy with aromatase inhibitor was started.

Plasmapheresis as treatment for hyperlipidemic pancreatitis

BACKGROUND

Severe hypertriglyceridemia with an accumulation of chylomicrons and triglyceride figures >1000 mg/dL can cause acute pancreatitis, a potentially fatal complication. The option of rapid reduction in triglyceride concentrations is attractive and possible with plasmapheresis.

METHODS

We present the results of an analysis of 11 patients admitted to the intensive care unit with severe hypertriglyceridemic pancreatitis and treated with plasmapheresis. The procedure was repeated until serum triglycerides were below 1000 mg/dL. We recorded anthropometric, clinical data as well as final outcome.

RESULTS

In eight patients a single plasma exchange was sufficient to reduce triglyceride figures <1000 mg/dL. Only three patients died, all with the worst severity indexes and who experienced the longest delay before the procedure.

CONCLUSIONS

Our results, together with a review of the literature, confirm the need for a randomized clinical trial to compare conventional treatment vs. plasmapheresis in patients with severe hypertriglyceridemic pancreatitis.

Acute pancreatitis during pregnancy: a review

This article aims to draw together recent thinking on pregnancy and acute pancreatitis (AP), with a particular emphasis on pregnancy complications, birth outcomes and management of AP during pregnancy contingent on the etiology. AP during pregnancy is a rare but severe disease with a high maternal-fetal mortality, which has recently decreased thanks to earlier diagnosis and some maternal and neonatal intensive care improvement. AP usually occurs during the third trimester or the early postpartum period. The most common causes of AP are gallstones (65 to 100%), alcohol abuse and hypertriglyceridemia. Although the diagnostic criteria for AP are not specific for pregnant patients, Ranson and Balthazar criteria are used to evaluate the severity and treat AP during pregnancy. The fetal risks from AP during pregnancy are threatened preterm labor, prematurity and in utero fetal death. In cases of acute biliary pancreatitis during pregnancy, a consensual strategy could be adopted according to the gestational age, and taking in consideration the high risk of recurrence of AP (70%) with conservative treatment and the specific risks of each treatment. This could include: conservative treatment in first trimester and laparoscopic cholecystectomy in second trimester. During the third trimester, conservative treatment or endoscopic retrograde cholangiopancreatography with biliary endoscopic sphincterotomy, and laparoscopic cholecystectomy in early postpartum period are recommended. A multidisciplinary approach, including gastroenterologists and obstetricians, seems to be the key in making the best choice for the management of AP during pregnancy.

Icosapent ethyl for treatment of elevated triglyceride levels

OBJECTIVES

To review the pharmacology, pharmacokinetics, clinical trial data, adverse effects, and formulary considerations of icosapent ethyl for the treatment of high triglyceride (TG) levels.

DATA SOURCES

A literature search with keywords Vascepa, icosapent ethyl, AMR101, and eicosapentaenoic acid of articles up to July 2013, along with the package insert for Vascepa and current guidelines for hypertriglyceridemia.

STUDY SELECTION/DATA EXTRACTION

Two phase-III, placebo-controlled, randomized, double-blind, 12-week clinical trials were included in this review: the MARINE trial and ANCHOR study. The MARINE trial consisted of mainly overweight Caucasian men with fasting TG ≥500 and ≤2000 mg/dL taking 4 g/day icosapent ethyl, 2 g/day, or placebo. The ANCHOR study consisted of mainly overweight Caucasians with type-2 diabetes mellitus on statin therapy, with fasting TG ≥200 and <500 mg/dL taking 4 g/day icosapent ethyl, 2 g/day, or placebo.

DATA SYNTHESIS

The MARINE trial showed a placebo-corrected median decrease in TG of 33.1% for patients receiving 4 g/day icosapent ethyl, with no significant change in low-density lipoprotein cholesterol (LDL-C) levels. TG was reduced by 19.7% in those taking 2 g/day. The ANCHOR study showed a placebo-corrected decrease in TG of 21.5% with a 6.3% decrease in LDL-C for patients taking 4 g/day icosapent ethyl as add-on to statin therapy. TG was reduced by 10.1% in those taking 2 g/day. The main adverse effect observed was joint pain (2.3%).

CONCLUSIONS

Icosapent ethyl is effective in reducing TG levels without increasing LDL-C, and has efficacy similar to other TG-lowering therapies with fewer adverse effects or interactions.

Severe hypertriglyceridemia-related acute pancreatitis

Acute pancreatitis is a potentially life-threatening complication of severe hypertriglyceridemia. In some cases, inborn errors of metabolism such as lipoprotein lipase deficiency, apoprotein C-II deficiency, and familial hypertriglyceridemia have been reported as causes of severe hypertriglyceridemia. More often, severe hypertriglyceridemia describes various clinical conditions characterized by high plasma levels of triglycerides (>1000 mg/dL), chylomicron remnants, or intermediate density lipoprotein like particles, and/or chylomicrons. International guidelines on the management of acute pancreatitis are currently available. Standard therapeutic measures are based on the use of lipid-lowering agents (fenofibrate, gemfibrozil, niacin, Ω-3 fatty acids), low molecular weight heparin, and insulin in diabetic patients. However, when standard medical therapies have failed, non-pharmacological approaches based upon the removal of triglycerides with therapeutic plasma exchange can also provide benefit to patients with severe hypertriglyceridemia and acute pancreatitis. Plasma exchange could be very helpful in reducing triglycerides levels during the acute phase of hyperlipidemic pancreatitis, and in the prevention of recurrence. The current evidence on management of acute pancreatitis and severe hypertriglyceridemia, focusing on symptoms, treatment and potential complications is reviewed herein.

Clinical features of hyperlipidemic acute pancreatitis: An analysis of 130 cases

AIM: To summarize and analyze the clinical features of hyperlipidemic acute pancreatitis (HLAP).

METHODS: Clinical data for patients with HLAP treated at our hospital from January 2006 to September 2012 were analyzed retrospectively. The clinical characteristics of HLAP were statistically analyzed. One hundred patients with acute biliary pancreatitis (ABP) were enrolled as controls.

RESULTS: A total of 102 HLPA patients (130 onsets) were enrolled in this study, accounting for 17.4 % of all AP patients. Patients with severe HLAP accounted for 23.1% of all HLAP patients. The mean age and percentage of patients with a serum amylase level greater than 3 times the upper limit of normal were significantly lower in HLAP patients than in ABP patients (both P < 0.05); however, HLAP patients were more likely to be associated with underlying metabolism syndrome and history of acute pancreatitis (both P < 0.05). The percentage of patients with a serum amylase level greater than 3 times the upper limit of normal was lower in HLAP patients with a TG level greater than or equal to 11.30 mmol/L than in HLAP patients with a TG level between 5.65-11.30 mmol/L (23.4% vs 41.5%, P < 0.05), but there were no significant differences in the proportion of severe cases (21.7% vs 28.6%, P > 0.05), hospitalization time (13.1 d ± 6.2 d vs 14.4 d ± 7.9 d, P > 0.05), and duration of abdominal pain (2.43 d ± 1.6 d vs 2.08 d ± 1.8 d, P > 0.05) between HLAP patients with different TG levels.

CONCLUSION: Low age of disease onset, male predominance, close relationship with metabolism syndrome, easy to recur, and unobvious increase in serum amylase are main clinical features of HLAP. Serum TG levels do not correlate with the severity of HLAP.

An alternative treatment in hypertriglyceridemia-induced acute pancreatitis in pregnancy: Plasmapheresis

Hormonal influences during pregnancy can compromise otherwise controlled lipid levels in women with familial hypertriglyceridemia and predispose to pancreatitis leading to increased morbidity in both mother and fetus. Both cholesterol and triglyceride levels in serum increase progressively during pregnancy. The mainstay of treatment includes dietary restriction of fatty meal and lipid-lowering medications. Experiences with plasmapheresis are limited. We report two cases of hypertriglyceridemia-induced acute pancreatitis during pregnancy, which were successfully treated by plasmapheresis.

Treatment of hyperlipidemic acute pancreatitis by continuous venovenous hemofiltration: an analysis of 24 cases

AIM: To observe the treatment effect of continuous veno-venous hemofiltration (CVVH) in patients with hyperlipidemic acute pancreatitis (HLP).

METHODS: Forty-nine HLP patients were randomly divided into two groups: CVVH group (A, n = 24) and control group (B, n = 25). Both groups underwent conventional therapy, and patients in group A additionally underwent CVVH. Heart rate (HR), respiration, PO₂/FiO₂, SaO₂, triglyceride (TG), IL-6 and TNF-α were monitored. APACHE Ⅱ score was used to evaluate patients' condition. The incidences of acute complications and survival rate were compared between the two groups.

RESULTS: After treatment by CVVH, HR, respiration, APACHE Ⅱ (10.8 ± 5.1 vs 15.5 ± 6.9, P < 0.05) as well as serum levels of TG, IL-6 and TNF-α (6.8 ± 3.7 vs 18.5 ± 6.3, 39.8 ± 16.7 vs 72.4 ± 25.1, 37.5 ± 14.1 vs 61.2 ± 16.1, all P < 0.05) decreased significantly. Seven days later, shock was corrected in both groups (P < 0.05). In group A, the incidences of acute renal failure (ARF) and acute respiratory distress syndrome (ARDS) were significantly decreased (5.0% vs 37.5%, 5.0% vs 25%, both P < 0.05). Compared to group B, group A had a higher survival rate (8.3% vs 20%).

CONCLUSION: CVVH is effective in treating HLP and is associated with a lower case fatality rate.

Transient infantile hypertriglyceridemia, fatty liver, and hepatic fibrosis caused by mutated GPD1, encoding glycerol-3-phosphate dehydrogenase 1

The molecular basis for primary hereditary hypertriglyceridemia has been identified in fewer than 5% of cases. Investigation of monogenic dyslipidemias has the potential to expose key metabolic pathways. We describe a hitherto unreported disease in ten individuals manifesting as moderate to severe transient childhood hypertriglyceridemia and fatty liver followed by hepatic fibrosis and the identification of the mutated gene responsible for this condition. We performed SNP array-based homozygosity mapping and found a single large continuous segment of homozygosity on chromosomal region 12q13.12. The candidate region contained 35 genes that are listed in Online Mendelian Inheritance in Man (OMIM) and 27 other genes. We performed candidate gene sequencing and screened both clinically affected individuals (children and adults with hypertriglyceridemia) and also a healthy cohort for mutations in GPD1, which encodes glycerol-3-phosphate dehydrogenase 1. Mutation analysis revealed a homozygous splicing mutation, c.361-1G>C, which resulted in an aberrantly spliced mRNA in the ten affected individuals. This mutation is predicted to result in a truncated protein lacking essential conserved residues, including a functional site responsible for initial substrate recognition. Functional consequences of the mutation were evaluated by measuring intracellular concentrations of cholesterol and triglyceride as well as triglyceride secretion in HepG2 (hepatocellular carcinoma) human cells lines overexpressing normal and mutant GPD1 cDNA. Overexpression of mutant GPD1 in HepG2 cells, in comparison to overexpression of wild-type GPD1, resulted in increased secretion of triglycerides (p = 0.01). This finding supports the pathogenicity of the identified mutation.

PAdvances in treatment of hyperlipidemic pancreatitis in pregnancy Hong-Mei Han, Xi-Xu Piao

Acute pancreatitis is a serious complication of pregnancy. In recent years, hypertriglyceridemia has become a common cause of acute pancreatitis, and up to 56% of pancreatitis cases during pregnancy are caused by hypertriglyceridemia. The majority of cases of hyperlipidemic pancreatitis in pregnancy belong to severe pancreatitis, and are commonly seen in the second and third trimester, easily recurrent, and dangerous. As hyperlipidemic pancreatitis in pregnancy is associated with a perinatal and maternal mortality of 20% to 50%, it seriously threatens maternal health and fetal lives. Now great efforts have been made to reduce the incidence of this complication and deaths of mothers and fetuses, and avoid the deformity of the baby. This article aims to review the progress in the treatment of hyperlipidemic pancreatitis in pregnancy.

Acute pancreatitis in pregnancy: an analysis of 20 cases

AIM: To explore the clinical features and management of acute pancreatitis in pregnancy (APIP).

METHODS: The clinical data for 20 patients with APIP who were treated at the People's Hospital of Wuhan University from April 2004 to January 2011 were retrospectively reviewed.

RESULTS: Of 20 patients with APIP, 2 were diagnosed in the second trimester, 17 in the third trimester, and 1 in the postpartum period; 3 (15%) received emergency operation, in which clearance of necrotic tissue in the pancreas and abdominal cavity drainage were performed after uterine-incision delivery; 11 (55%, all >33 weeks of pregnancy) received uterine-incision delivery; 5 (25%) were discharged in a stable condition; 19 (95%) recovered, and 1 (5%) died of multiple organ dysfunction syndrome (MODS); 14 (70%) terminated pregnancy, and 5 (25%) continued the pregnancy; 2 had pre-admission fetal death in utero.

CONCLUSION: APIP often occurs in the middle and late pregnancy. Conservative medical therapy is usually recommended first for APIP. Individualized therapy and termination of pregnancy may be beneficial to maternal and neonatal safety in some cases.

Emergent therapy with therapeutic plasma exchange in acute recurrent pancreatitis due to severe hypertriglyceridemia

Hypertriglyceridemia causes acute pancreatitis in 1.3-3.8% of patients. We report here on two cases with severe (triglyceride level >1000 mg/dL) hypertriglyceridemia-induced acute recurrent pancreatitis. Both patients had uncontrolled hypertriglyceridemia and suffered from acute pancreatitis. No cause of secondary hypertriglyceridemia was detected. While stage E pancreatitis (Ranson's score: 2) was diagnosed in the first case, stage D pancreatitis with a null Ranson's score was detected in the second case. Both patients were treated with classical treatment with fluid replacement, analgesic, antibiotics and discontinuation of oral intake. Therapeutic plasma exchange (TPE) with fresh frozen plasma was performed consecutively and with two procedures on the 2nd and 3rd day in the first case. After TPE, while the triglyceride levels decreased from 4408 to 302 mg/dL, the amylase levels dropped from 4234 to 171 IU/L. In the second case, TPE was performed once daily. After TPE, the levels of triglyceride and amylase decreased from 2210 mg/dL and 1618 IU/L to 154 mg/dL and 110 IU/L, respectively. Local and systemic complications due to acute pancreatitis were not observed. Clinical signs and laboratory values improved. At the two-year follow-up of both patients, acute pancreatitis had not recurred with regular fenofibrate treatment. Hypertriglyceridemia should be considered in patients with acute recurrent pancreatitis. Although there is no definitive evidence for early application of TPE in severe hypertriglyceridemia-induced acute pancreatitis yet, therapy with TPE may be of benefit, improving the clinical course.

Hyperlipidemia-associated pancreatitis in pregnancy managed with fenofibrate

BACKGROUND

Pancreatitis is a concerning clinical event during pregnancy, with high morbidity and mortality rates for mother and fetus. Hypertriglyceridemia is considered a rare cause of pancreatitis in pregnancy, with the majority of reported cases being associated with the lipid metabolism disorders.

CASE

We report on a case of hypertriglyceridemia-induced pancreatitis in a woman presenting at 32 weeks of gestational age. Her dyslipidemia was not controlled with diet alone, necessitating medical intervention. Fenofibrate was used successfully. Recurrence of pancreatitis during the pregnancy was avoided, and a healthy neonate was delivered at 35 weeks of gestation.

CONCLUSION

Fenofibrate was used safely and successfully during pregnancy in this case of hypertriglyceridemia-associated pancreatitis refractory to conservative measures.

Malignancy-associated dyslipidemia

Cholesterol and triglycerides, important lipid constituents of cell, are essential to carry out several vital physiological functions. Lipids might be associated with cancers because they play a key role in the maintenance of cell integrity. The pathway for cholesterol synthesis may also produce various tumorigenic compounds and cholesterol serves as a precursor for the synthesis of many sex hormones linked to increased risk of various cancers. In some malignant diseases, blood cholesterol undergoes early and significant changes. The mechanism for the link between cancer and cholesterol remains controversial. The dates from studies are confusing because both hypolipidemia and hypercholesterolemia might be connected with malignancy. Not only cancers but also antineoplastic therapies have an influence on lipid profile. There are also dates suggesting that antihyperlipemic drugs might nfluenced malignancy.

[Acute pancreatitis caused by hypertriglyceridemia]

Hypertriglyceridemia is reported to cause 1-7% of the cases of acute pancreatitis.

AIM

The aim of the present study was to assess the clinical features and management of pancreatitis with hypertriglyceridemia in our tertiary center.

METHODS

Between 1 January 2007 and 31 December 2009, patients with a diagnosis of hypertriglyceridemia-induced acute pancreatitis were reviewed. Patients with pancreatitis and serum triglyceride levels greater than 11.3 mmol/l (≈1000 mg/dl) were included. Acute pancreatitis with other etiologies was excluded.

RESULTS

26 patients (2 women, 24 men; median age at presentation 42 years; range: 22-70) were diagnosed with hypertriglyceridemia‑induced acute pancreatitis; 3 patients had altogether 7 relapses. The total number of cases was 33, which accounted for 4.71% of the total number of acute pancreatitis cases in the examined period. There was a failure in diet in 30.3% and a history of regular alcohol abuse in 57.6% of the cases. A history of diabetes mellitus was present in 38.1%, and gallstones in 9.1% of the cases. Lactescent serum was described on admission in 27.3%. Mean triglyceride level was 47.24 mmol/l (≈4181 mg/dl; 12.4-103.8 mmol/l). Amylase level was elevated to three times the normal in 54.5%, and that of lipase to three times the normal in 58.8%. Necrotizing acute pancreatitis was diagnosed in 7 patients (26.9%), and pseudocyst in 8 patients (30.7%). Administration of insulin, heparin, plasmapheresis and fibrates lowered the triglyceride to 3.71 mmol/l (≈328 mg/dl).

CONCLUSION

The clinical course of acute pancreatitis with hypertriglyceridemia does not differ from acute pancreatitis of other causes. Interestingly, levels of serum pancreatic enzymes may be normal or only minimally elevated. Insulin, heparin, plasmapheresis and fibrates effectively reduce lipid levels and relieve symptoms. A low triglyceride level is necessary to prevent relapses.

Acute pancreatitis

Acute pancreatitis (AP) is an important cause of morbidity and mortality worldwide and the annual incidence appears to be increasing. It presents as a mild self-limiting illness in 80% of patients. However, one-fifth of these develop a severe complicated life-threatening disease requiring intensive and prolonged therapeutic intervention. Alcohol and gallstone disease remain the commonest causes of AP but metabolic abnormalities, obesity and genetic susceptibility are thought be increasingly important aetiological factors. The prompt diagnosis of AP and stratification of disease severity is essential in directing rapid delivery of appropriate therapeutic measures. In this review, the range of diagnostic and prognostic assays, severity scoring systems and radiological investigations used in current clinical practice are described, highlighting their strengths and weaknesses. Increased understanding of the complex pathophysiology of AP has generated an array of new potential diagnostic assays and these are discussed. The multidisciplinary approach to management of severe pancreatitis is outlined, including areas of controversy and novel treatments.

Therapeutic plasma exchange in patients with severe hypertriglyceridemia: a multicenter study

Extremely high plasma triglyceride (TG) concentration is a recognized risk factor for acute pancreatitis (AP). In order to evaluate the therapeutic efficacy of plasma-exchange plasmapheresis in treating patients with severe hypertriglyceridemia (sHTG), 17 patients who had not responded to conventional medical therapy (fat-free diet plus pharmaceutical interventions) were referred for therapeutic plasma exchange (TPE) in a multicenter frame case series study. Two hundred seventeen TPE sessions were performed, and therapy is ongoing for five (30%) of the patients. After treatment, the mean plasma TG and total cholesterol concentrations were significantly reduced from 1929 and 510 mg/dL, to 762 and 227 mg/dL, respectively (P < or = 0.001 in both cases). In most cases, the interval between treatments was related to the clinical presentation and individual circumstances. The removal of TG-rich lipoproteins prevented relapses of AP. In this case series, TPE is confirmed as a safe and reliable method for treating patients with refractory sHTG when a severe complication, such as AP, is clinically demonstrated or can be actively prevented. Therefore, in cases where standard medical approaches fail to promote the clearance of TGs from plasma and a high risk of first or second hypertriglyceridemic pancreatitis persists, TPE provides a therapeutic option for preventing life-threatening sHTG.

Long-term plasma exchange for severe refractory hypertriglyceridemia: a decade of experience demonstrates safety and efficacy

Hypertriglyceridemia (hyperTG) is a common form of dyslipidemia and is frequently associated with premature coronary disease, and when severe, recurrent events of pancreatitis may occur. The management of hyperTG is generally medical (life style modification, medications). Plasma exchange (PE) has been reported to be useful in emergency situations particularly when acute pancreatitis results from extreme hyperTG. To our knowledge, there is only one report on long-term use of PE for hyperTG. We here report our results of long-term treatment of hyperTG in 6 patients with Frederickson Type V hyperlipidemia who had recurrent attacks of pancreatitis due to hyperTG refractory to medical therapy. PE was performed from one to eight times a month, mostly using a Cobe Spectra apparatus. In total, our center has performed a total of 1,593 PE sessions for hyperTG. There were no safety issues associated with PE for hyperTG other than occasional access problems (clotted fistula, IV access problems). Determination of plasma TG levels before and after PE demonstrated high efficiency of TG removal (42% to 58% reduction). There was marked clinical improvement in recurrent pancreatitis; patients had a major decrease in episodes (39% to 100%) while on regular PE, as long as they adhered to the treatment schedule. We conclude that long-term PE for hyperTG, while costly, is feasible and safe and may reduce recurrent attacks of pancreatitis.

Severe hypertriglyceridemia and pancreatitis: presentation and management

PURPOSE OF REVIEW

Hypertriglyceridemia (HTG) is a well recognized cause of acute pancreatitis accounting for approximately up to 10% of all cases and even up to 50% of all cases in pregnancy. Both primary and secondary disorders of lipoprotein metabolism may be associated with hypertriglyceridemic pancreatitis (HTGP). The purpose of this review is to provide an overview of the current studies on presentation and management of HTGP.

RECENT FINDINGS/CONCLUSION

Hydrolysis of triglycerides by pancreatic lipase and formation of free fatty acids that induce inflammatory changes are postulated to account for the development of HTGP, yet the exact pathophysiology remains unclear. The clinical features of patients with HTGP are generally not different from patients with acute pancreatitis of other causes, and there is some evidence that HTGP is associated with a higher severity or a higher complication rate. There is no clear evidence as to which HTG patients will develop pancreatitis. Several studies have evaluated the effect of apheresis, the benefit of insulin and/or heparin treatment and the use of different antihyperlipidemic agents in HTGP. Dietary modifications resemble the key features in the long-term management of HTG. Whether HTG may cause chronic pancreatitis in the long-term follow-up remains controversial.

Rheologic reflection in hypertriglyceridemia-induced pancreatitis

Triglyceride levels greater than 1,000 mg/dL may cause severe pancreatitis, and there is mounting evidence for the use of plasmapheresis to remove triglycerides for the treatment of triglyceride-induced pancreatitis. The failure of continuous venovenous hemodialysis (CVVHD) due to severe lipemia, necessitating plasmapheresis in the early phase of severe acute hypertriglyceridemia-induced pancreatitis, is reported. We suggest that in the setting of hypertriglyceridemia-induced pancreatitis with urgent indication for dialysis, plasmapheresis be initiated prior to CVVHD to prevent rheologic failure.

Acute pancreatitis: risk of recurrence and late consequences of the disease

Research into the clinical management of acute pancreatitis has primarily focused on the immediate complications of the disease, whereas its late consequences have received less attention. These late sequelae of acute pancreatitis refer to complications that arise after the convalescence period, which lasts for 3-6 months after the initial episode. In patients who do not undergo necrosectomy that involves removal of the exocrine gland, pancreatic exocrine function usually improves rather than deteriorates during follow-up. By contrast, glucose intolerance is likely to worsen over time in all patients with acute pancreatitis. Despite the risk of late complications for patients with acute pancreatitis, their long-term quality of life is usually good. The number of pancreatitis episodes a patient has experienced is an important factor that determines the severity of late complications of acute pancreatitis. Risk factors for the recurrence of acute pancreatitis episodes have now been identified. This Review focuses on data from studies that investigated the risk factors for recurrent attacks of acute pancreatitis, and discusses the late consequences of this disease.

Lipoic acid improves hypertriglyceridemia by stimulating triacylglycerol clearance and downregulating liver triacylglycerol secretion

Elevated blood triacylglycerol (TG) is a significant contributing factor to the current epidemic of obesity-related health disorders, including type-2 diabetes, nonalcoholic fatty liver disease, and cardiovascular disease. The observation that mice lacking the enzyme sn-glycerol-3-phosphate acyltransferase are protected from insulin resistance suggests the possibility that the regulation of TG synthesis be a target for therapy. Five-week-old Zucker Diabetic Fatty (ZDF) rats were fed a diet containing (R)-alpha-lipoic acid (LA, approximately 200mg/kg body weight per day) for 5 weeks. LA offset the rise in blood and liver TG by inhibiting liver lipogenic gene expression (e.g. sn-glycerol-3-phosphate acyltransferase-1 and diacylglycerol O-acyltransferase-2), lowering hepatic TG secretion, and stimulating clearance of TG-rich lipoproteins. LA-induced TG lowering was not due to the anorectic properties of LA, as pair-fed rats developed hypertriglyceridemia. Livers from LA-treated rats exhibited elevated glycogen content, suggesting dietary carbohydrates were stored as glycogen rather than becoming lipogenic substrate. Although AMP-activated protein kinase (AMPK) reportedly mediates the metabolic effects of LA in rodents, no change in AMPK activity was observed, suggesting LA acted independently of this kinase. The hepatic expression of peroxisome proliferator activated receptor alpha (PPARalpha) target genes involved in fatty acid beta-oxidation was either unchanged or decreased with LA, indicating a different mode of action than for fibrate drugs. Given its strong safety record, LA may have potential clinical applications for the treatment or prevention of hypertriglyceridemia and diabetic dyslipidemia.