Treatment of severe familial hypertriglyceridemia during pregnancy with very-low-fat diet and n-3 fatty acids

Current Diagnosis and Management of Primary Chylomicronemia

Primary chylomicronemia (PCM) is a rare and intractable disease characterized by marked accumulation of chylomicrons in plasma. The levels of plasma triglycerides (TGs) typically range from 1,000 - 15,000 mg/dL or higher.

PCM is caused by defects in the lipoprotein lipase (LPL) pathway due to genetic mutations, autoantibodies, or unidentified causes. The monogenic type is typically inherited as an autosomal recessive trait with loss-of-function mutations in LPL pathway genes ( LPL , LMF1 , GPIHBP1 , APOC2 , and APOA5 ). Secondary/environmental factors (diabetes, alcohol intake, pregnancy, etc.) often exacerbate hypertriglyceridemia (HTG).

The signs, symptoms, and complications of chylomicronemia include eruptive xanthomas, lipemia retinalis, hepatosplenomegaly, and acute pancreatitis with onset as early as in infancy. Acute pancreatitis can be fatal and recurrent episodes of abdominal pain may lead to dietary fat intolerance and failure to thrive.

The main goal of treatment is to prevent acute pancreatitis by reducing plasma TG levels to at least less than 500-1,000 mg/dL. However, current TG-lowering medications are generally ineffective for PCM. The only other treatment options are modulation of secondary/environmental factors. Most patients need strict dietary fat restriction, which is often difficult to maintain and likely affects their quality of life.

Timely diagnosis is critical for the best prognosis with currently available management, but PCM is often misdiagnosed and undertreated. The aim of this review is firstly to summarize the pathogenesis, signs, symptoms, diagnosis, and management of PCM, and secondly to propose simple diagnostic criteria that can be readily translated into general clinical practice to improve the diagnostic rate of PCM. In fact, these criteria are currently used to define eligibility to receive social support from the Japanese government for PCM as a rare and intractable disease.

Nevertheless, further research to unravel the molecular pathogenesis and develop effective therapeutic modalities is warranted. Nationwide registry research on PCM is currently ongoing in Japan with the aim of better understanding the disease burden as well as the unmet needs of this life-threatening disease with poor therapeutic options.

Treatment of Severe Hypertriglyceridemia During Pregnancy With High Doses of Omega-3 Fatty Acid and Plasmapheresis

Objective

Severe hypertriglyceridemia carries increased health risks, including the development of pancreatitis. The objective of this study was to report on management of 2 cases with severe gestational hypertriglyceridemia.

Cases

In case 1, a 33-year-old pregnant woman presented with serum triglyceride level of 14 000 mg/dL after discontinuing hypolipidemic medications. She was treated with Lovaza 12 g/day, and serum triglyceride remained near normal at level of less than 800 mg mg/dL until delivery. In case 2, a 28-year-old patient (29^th week gestation) presented with acute pancreatitis and triglycerides >4000 mg/dL. She was treated with Gemfibrozil, Lovaza, insulin infusion, subcutaneous heparin, and escalated to plasmapheresis. She successfully delivered a baby at the week of 36^th and her triglyceride level was 304 mg/dL after that.

Discussion

Case 1 was treated with high-dose Lovaza and case 2 was treated with plasmapheresis successfully. Triglyceride levels were reduced to less than 500 mg/dL until delivery of healthy babies in both cases.

Conclusion

Omega-3 fatty acids and plasmapheresis may be effective and safe to treat pregnant women with severe hypertriglyceridemia and pancreatitis.

Maternal lipids in pre-eclampsia: innocent bystander or culprit?

Pre-eclampsia continues to be a challenge--to understand the underlying pathogenesis and to prevent or treat in the clinical setting. One area of potential therapies opening up is treatment of maternal lipids and clinical trials are underway using statins in early pre-eclampsia. At present, most potential therapies to treat lipids cannot be recommended for general use in pregnancy and if we were to target maternal lipids to reduce rates of pre-eclampsia, very large numbers of women may need to be treated. Prior to reaching that point, we first need to understand whether maternal lipids are pathogenic in the processes underlying pre-eclampsia. The aim of this review is to examine the role of lipids in the pathogenesis and outcomes of pre-eclampsia, how abnormal lipid genes may be implicated and consider whether treatment of hyperlipidemia has a more general place in the prevention or treatment of pre-eclampsia.

Management of hypertriglyceridaemia-induced acute pancreatitis in pregnancy

INTRODUCTION

Acute pancreatitis is a recognised rare complication in pregnancy. The reported incidence varies between 3 and 7 in 10 000 pregnancies and is higher in the third trimester. The commonest causes in pregnancy include gallstones, alcohol and hypertriglyceridaemia. Non-gallstone pancreatitis is associated with more complications and poorer outcome with hypertriglyceridaemia-induced acute pancreatitis having mortality rates ranging from 7.5 to 9.0% and 10.0 to 17.5% for mother and foetus, respectively.

CASE HISTORY

A 40-year-old para 4 woman, who presented at 15(+4) weeks' gestation, was diagnosed with acute pancreatitis. Past medical history included Graves' disease and hypertriglyceridaemia. Fenofibrate was discontinued immediately after discovery of the pregnancy. Initial investigations showed elevated amylase (475.0 µ/L) and triglycerides (46.6 mmol/L). Imaging revealed an inflamed pancreas without evidence of biliary obstruction/gallstones hence confirming the diagnosis of hypertriglyceridaemia-induced acute pancreatitis. Laboratory tests gradually improved (triglyceride 5.2 mmol/L on day 17). On day 18, ultrasound confirmed foetal demise (18(+1) weeks) and a hysterotomy was performed as she had had four previous caesarean sections.

CONCLUSION

Management of acute pancreatitis in pregnancy requires a multi-disciplinary approach. Hypertriglyceridaemia-induced acute pancreatitis has poor outcomes when diagnosed in early pregnancy. Identifying those at risk pre-pregnancy and antenatally can allow close monitoring through pregnancy to optimise care.

Titrating lovaza from 4 to 8 to 12 grams/day in patients with primary hypertriglyceridemia who had triglyceride levels >500 mg/dl despite conventional triglyceride lowering therapy

Background

Omega-3 fatty acids are important in treatment of severe primary hypertriglyceridemia (HTG). In 15 patients with severe primary HTG (TG >500 mg/dl despite conventional TG lowering therapy), we assessed efficacy-safety of sequential monthly treatment with Lovaza, 4 to 8 to 12 g/day.

Methods

With TG >500 mg/dl despite Type V diet, hyperinsulinemia and diabetes control, and fibric acids, Lovaza (4 g/d) was added for 1 month, and if TG remained >500 mg/dl, increased to 8 g/d for 1 month, and then to 12 g/d for 1 month, and subsequently reduced to 4 g/day for 4 months.

Results

Primary HTG, median TG 884 mg/dl, 14 men, 1 woman, all white, age 50 ± 7 years, 12 non-diabetic, 3 with stable diabetes control. Weight and diet held stable throughout. In 5 patients, after 1, 2, and 3 months on 4 g/day, TG fell <500, mean 1390 to 234 (−83%, p<.0001), to 135 (−90%, p<.0001), and 158 mg/dl (−89%, p<.0001), with a negative TG slope, p=.0013. Non-HDLC fell from 320 to 177 (−45%, p=.001), to 152 (−53%, p=.0002), and to 163 (−49%, p=.0004), with a negative slope, p=.01. In 10 patients, with Lovaza increased from 4 to 8 to 12 g, 3 failed to respond. In 7 of these 10 patients, TG fell 37% from 1075 to 672 on 4 g (p=.006), to 577 on 8 g (−46%, p=.0009), and to 428 mg/dl (−60%, p<.0001) on 12 g/day, with a negative TG slope, p=.0018. TG on 12 g/day was lower than on 8 g/day, p =.03. Non-HDLC fell from 245 to 217 mg/dl (−11%) on 4 g/day, to 203 (−17%, p=.01) on 8 g/day, and to 192 (−22%, p=.003) on 12 g/day, with a negative slope, p=.016. Compared to pre-Lovaza baseline, no abnormal measures developed in safety tests. The 4, 8, and 12 g/d Lovaza doses were well tolerated.

Conclusion

Titration of Lovaza from 4 to 8 to 12 g/d safely offers an effective way to lower TG beyond conventional 4 g therapy.

Triglyceride metabolism in pregnancy

During pregnancy, complex changes occur in lipid profiles. From the 12th week of gestation, phospholipids, cholesterol (total, LDL, HDL), and triglycerides (TG) increase in response to estrogen stimulation and insulin resistance. Transition to a catabolic state favors maternal tissue lipid use as energy sources, thus sparing glucose and amino acids for the fetus. In addition, maternal lipids, that is, cholesterol, are available for fetal use in building cell membranes and as precursor of bile acids and steroid hormones. It is also required for cell proliferation and development of the growing body. Free-fatty acids (FFA), oxidized in the maternal liver as ketone-bodies, represent an alternative fuel for the fetus. Maternal hypertriglyceridemia (vs. other lipids) has many positive effects such as contributing to fetal growth and development and serving as an energy depot for maternal dietary fatty acids. However, increased TG during pregnancy appears to increase risk of preeclampsia and preterm birth. Some have suggested that maternal hypertriglyceridemia has a role in increasing cardiovascular risk later in life. This chapter reviews lipid metabolism during pregnancy to elucidate its effect on fetal growth and its potential role in pregnancy-associated complications and future cardiovascular risk.

Acute pancreatitis in pregnancy: an overview

Acute pancreatitis is rare in pregnancy but it is associated with increased incidence of maternal and fetal mortality. It should be considered in the differential diagnosis of upper quadrant abdominal pain with or without nausea and vomiting. The commonest identified causes of acute pancreatitis in pregnancy are gallstones, alcohol and hypertriglyceridemia. The main laboratory finding is increased amylase activity. Appropriate investigations include ultrasound of the right upper quadrant and measurement of serum triglycerides and ionized calcium. Management of gallstone pancreatitis is controversial, although laparoscopic cholecystectomy and endoscopic retrograde cholangiopancreatography (ERCP) are often used and may be associated with lower complication rates. In hypertriglyceridemia-induced acute pancreatitis ω-3 fatty acids and even therapeutic plasma exchange can be used. We also discuss preventive measures.

Hypertriglyceridemic acute pancreatitis during pregnancy: prevention with diet therapy and omega-3 fatty acids in the following pregnancy

Acute pancreatitis complicating pregnancy is rare and has previously been associated with high mortality rates. We report a case of repeated hypertriglyceridemia during pregnancy. During the patient's first pregnancy, acute pancreatitis was elicited in the third trimester by pregnancy-induced hypertriglyceridemia. The patient was treated successfully with a conservative treatment course. The hypertriglyceridemia recurred during her second pregnancy. She carried the pregnancy to term without incident while maintaining a diet low in fat diet and high in omega-3 fatty acids. Early diagnosis and intensive treatment can help to preserve the lives of the patient and the fetus. Prophylactic diet therapy and omega-3 fatty acids may prevent recurrent hypertriglyceridemia during pregnancy.

Current issues: women and bipolar disorder

While the treatment of bipolar disorder (BD) is typically complex, the treatment of women with bipolar disorder is even more challenging because clinicians must also individualize treatment based on the potential for pregnancy, drug interactions with oral contraceptives, and an increased risk of endocrine diseases that can either impact the course of illness or become manifest with some treatments. Women with BD should be checked for hypothyroidism, and if prescribed antidepressants, carefully watched for rapid cycling or a mood switch to mania, hypomania, or a mixed state. Several medications interact with oral contraceptives or increase the risk of developing polycystic ovary syndrome. Consideration of possible pregnancy is essential, and should be planned in advance whenever possible. Rates of recurrence have been shown to be equal in pregnant and nonpregnant women with BD. Risks of medication to the fetus at various points of development must be balanced against the risks of not treating, which is also detrimental to both fetus and mother. The postpartum period is a time of especially high risk; as many as 40% to 67% of women with BD report experiencing a postpartum mania or depression. The decision to breastfeed must also take into account the adverse impact of sleep deprivation in triggering mood episodes. In order to best address these issues, clinicians must be familiar with the data and collaborate with the patient to assess risks and benefits for the individual women and her family.

[Severe gestational hypertriglyceridemia: related complications and management]

We present two cases of severe hypertriglyceridemia (HTG>10g/l) in pregnancy. The first reports the case of a primigravida with mild HTG before conception. Triglycerides (TG) increased thereafter (20.9g/l) during pregnancy causing pancreatitis and in utero fetal death at 24 weeks' gestation (WG). The second deals with the de novo occurrence of a severe HTG (19g/l) diagnosed incidentally at 34 WG and complicated by acute renal failure. Severe HTG in pregnancy threatens maternal and fetal prognosis. We have summarized the curative and preventive management of gravidic HTG.

Omega-3 fatty acids in bipolar disorder: clinical and research considerations

Several lines of evidence suggest that omega-3 fatty acids may be important in the pathophysiology, treatment or prevention of bipolar disorder (BD). Electronic and manual searches were conducted in order to review the literature relevant to the etiology and treatment of BDs with omega-3 fatty acids. We also present data from a randomized, double-blind, placebo-controlled pilot study conducted at three sites (N = 10) comparing an omega-3 fatty acid (docosahexaenoic acid, DHA) versus placebo, added to psychosocial treatment for women with BD who chose to discontinue standard pharmacologic treatment while attempting to conceive. While some epidemiologic and preclinical data support the role of omega-3 fatty acids in BD, clinical trials to date have yielded conflicting results. In our pilot study of 10 Caucasian women taking DHA while attempting to conceive (BP1 = 9, BPII = 1), age 27-42 years, DHA was well tolerated and suggests that a larger study would be feasible. The elucidation of the potential role of omega-3 fatty acids as a treatment for BD requires further study. The current data are not sufficient to support a recommendation of monotherapy treatment as a substitute for standard pharmacologic treatments. However, judicious monotherapy in selected clinical situations, or adjunctive use, may be warranted pending further data from adequately powered controlled clinical trials. Our pilot trial of DHA in women who plan to stop conventional psychotropics in order to conceive suggests that such trials are feasible.

Maternal erythrocyte omega-3 and omega-6 fatty acids, and plasma lipid concentrations, are associated with habitual dietary fish consumption in early pregnancy

OBJECTIVES

We investigated the relationship between selected maternal erythrocyte omega-3 and omega-6 polyunsaturated fatty acids (PUFA) and plasma lipids in early pregnancy and reported habitual fish consumption during the periconceptional period.

DESIGN AND METHODS

This cohort study included 923 pregnant women who reported periconceptional dietary habits and provided a blood sample before 20 weeks of gestation. PUFA was determined by gas chromatography and plasma lipids by standard enzymatic methods. Differences in erythrocyte PUFA and plasma lipid concentrations were estimated using linear regression.

RESULTS

Mean erythrocyte eicosapentanoic acid and other PUFA content (%/total) were positively associated with frequency of self-reported fish consumption. Arachidonic acid was inversely related with frequent fish consumption (p trend <0.001). Women who consumed fish >twice/week had lower plasma triglyceride (-11.5 mg/dl) and higher HDL-cholesterol (+2.8 mg/dl) concentrations than women consuming fish <once/week.

CONCLUSIONS

These results support findings of inverse relation between fish consumption and preeclampsia risk.

Severe hypertriglyceridemia and acute pancreatitis during pregnancy: treatment with gemfibrozil

OBJECTIVE

To describe the effect of gemfibrozil therapy during pregnancy in a woman with severe hypertriglyceridemia.

METHODS

We present a case report, with details of lipid levels throughout several attempted pregnancies, and discuss other similar published studies.

RESULTS

In a 22-year-old woman, severe acute pancreatitis due to hypertriglyceridemia developed during her first pregnancy. After a prolonged hospital course, the outcome was fetal demise. The patient was subsequently treated with gemfibrozil, which controlled the hypertriglyceridemia. A second pregnancy ended with a therapeutic abortion at 1 month because of the possible risk of pancreatitis. Gemfibrozil therapy was instituted but subsequently discontinued when she was discovered to be pregnant again, at approximately 10 weeks of gestation; the potential risks involved with the use of this drug during pregnancy were unknown. Because of the patient's strong desire to maintain the pregnancy, gemfibrozil treatment was resumed 1 week later in order to help prevent recurrent pancreatitis. The patient ultimately delivered a fullterm healthy boy, and she had no recurrence of pancreatitis or other complications.

CONCLUSION

In selected patients at high risk for pancreatitis, the potential risk of gemfibrozil use during pregnancy may be offset by its benefits in the management of severe hypertriglyceridemia.

An observational study of severe hypertriglyceridemia, hypertriglyceridemic acute pancreatitis, and failure of triglyceride-lowering therapy when estrogens are given to women with and without familial hypertriglyceridemia

BACKGROUND

We assessed severe hypertriglyceridemia, hypertriglyceridemic acute pancreatitis, and failure of triglyceride-lowering therapy when estrogens were given to 56 women with and without familial hypertriglyceridemia. The 56 women had been consecutively referred to our center over a 3-year period because of triglycerides >400 mg/dl despite diet-drug treatment and/or a history of hypertriglyceridemic acute pancreatitis (AP). Of the 56 women, 17 had received estrogen replacement therapy (ERT), hormone replacement (HRT, n=6), or selective estrogen receptor modulators (SERM, n=1).

METHODS

After study at entry, in 56 women (median age, 52 years), 36 with familial hypertriglyceridemia, to lower triglycerides, estrogens and SERMs (hormone treatment, HT) were stopped; a very low fat diet (<15% of calories), gemfibrozil (1.2-1.5 mg/day), and omega-3-fatty acid (4-12 g/day) were started, with restudy 2-4 weeks later.

RESULTS

Of the 56 women, 24 (43%) were taking HT at entry, with median fasting triglycerides 1270 mg/dl in the HT group and 1087 mg/dl in the no-HT group. Seventeen women (30%) had a history of AP, nine of whom (53%) were/had been on HT at the development of AP. Significant positive correlates of triglycerides at entry in a stepwise regression model were hemoglobin A(1C) (partial r(2)=10.7%, p<0.05) and an interaction between estrogen use and familial hypertriglyceridemia (partial r(2)=15%, p=0.017). After 2-4 weeks on therapy, median triglycerides in the previous-HT group fell from 1270 to 284 mg/dl (p<0.0001) and in the no-HT group from 1087 to 326 mg/dl (p<0.0001).

CONCLUSIONS

Before starting HT, to avoid HT induced hypertriglyceridemic AP and exacerbation of overt or covert familial hypertriglyceridemia, triglycerides must be measured. HT is contraindicated in women with preexisting hypertriglyceridemia (triglycerides> or =500 mg/dl). Triglyceride-lowering diets and drugs often fail in the presence of HT and/or poorly controlled diabetes mellitus, but commonly succeed when HT is stopped and diabetes mellitus is tightly controlled.

Successful pregnancy outcome in a patient with severe chylomicronemia due to compound heterozygosity for mutant lipoprotein lipase

OBJECTIVES

Familial chylomicronemia syndrome is characterized by massive accumulation of plasma chylomicrons, which typically results from an absolute deficiency of lipoprotein lipase (LPL). Chylomicronemia in pregnancy is a rare, but serious clinical problem and can be found in patients with underlying molecular defects in the LPL gene. We report the course and treatment of an 18 yr-old primigravida who had LPL deficiency and hypertriglyceridemia since birth. We also analyzed the molecular basis of her LPL deficiency.

DESIGN AND METHODS

The patient's antenatal course was complicated by extreme elevations of plasma triglycerides. Her management included a very low fat diet, pharmacotherapy with gemfibrozil in the third trimester, and intermittent hospitalization with periods of fasting supplemented by IV glucose feeding. We used DNA sequencing to determine whether mutations in LPL were present.

RESULTS

At 38 weeks of gestation, labor was induced, and the patient delivered a healthy 2.77 kilogram male. Postnatal triglycerides fell to prenatal levels. DNA sequencing showed that she was a compound heterozygote for mutant LPL: I > T194 and R > H243.

CONCLUSIONS

This experience indicates that vigilance is required during pregnancy in patients with familial chylomicronemia due to mutant LPL. Gemfibrozil was used in this patient without apparent adverse effects. Compound heterozygosity for LPL mutations is an important underlying mechanism for LPL deficiency.