1
|
Kay HY, Jang HY, Kim IW, Oh JM. Fibrates and risk of congenital malformations: a nationwide cohort study in South Korea. Arch Gynecol Obstet 2024; 310:1967-1973. [PMID: 38553644 PMCID: PMC11393199 DOI: 10.1007/s00404-023-07357-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 12/19/2023] [Indexed: 09/13/2024]
Abstract
PURPOSE To examine the association between maternal prescriptions for fibrates and congenital malformations in live births. METHODS Nationwide retrospective cohort study was conducted using the data sourced from the Korean National Health Insurance database. A cohort of 756,877 completed pregnancies linked to live-born infants in 215,600 women with dyslipidemia between 2012 and 2021. The study compared data on congenital anomalies between pregnancies who were exposed to fibrates and those who were not exposed to fibrates in the first trimester. Odds ratios (OR) were calculated by a multivariable analyses using logistic regression models to adjust for potential confounders. RESULTS 260 pregnancies (0.12%) were exposed to fibrates during the first trimester. The prevalence of malformations in exposed offspirng was 10.77%, not significantly different compared with 9.68% in offspring of women who were not prescribed fibrates during pregnancy in patients with dyslipidemia (OR 1.13; 95% CI 0.75-1.70). CONCLUSION This study implies that the use of fibrates during pregnancy may be safe, as it did not show any association with congenital anomalies. However, caution is warranted due to an elevated risk associated with prolonged exposure.
Collapse
Affiliation(s)
- Hee Yeon Kay
- College of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University, Seoul, Republic of Korea
| | - Ha Young Jang
- College of Pharmacy, Gachon University, Incheon, 21936, Republic of Korea
| | - In-Wha Kim
- College of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University, Seoul, Republic of Korea
| | - Jung Mi Oh
- College of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University, Seoul, Republic of Korea.
| |
Collapse
|
2
|
Formisano E, Proietti E, Perrone G, Demarco V, Galoppi P, Stefanutti C, Pisciotta L. Characteristics, Physiopathology and Management of Dyslipidemias in Pregnancy: A Narrative Review. Nutrients 2024; 16:2927. [PMID: 39275243 PMCID: PMC11397408 DOI: 10.3390/nu16172927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2024] [Revised: 08/28/2024] [Accepted: 08/30/2024] [Indexed: 09/16/2024] Open
Abstract
Dyslipidemia is a significant risk factor for atherosclerotic cardiovascular disease (ASCVD). During pregnancy, physiological changes elevate cholesterol and triglyceride levels to support fetal development, which can exacerbate pre-existing conditions and lead to complications such as pre-eclampsia, gestational diabetes, and increased ASCVD risk for both mother and child. Effective management strategies are necessary, especially for pregnant women with inherited forms of dyslipidemia (i.e., familial hypertriglyceridemia, hyperchylomicronemia), where personalized dietary adjustments are crucial for successful pregnancy outcomes. Pharmacological interventions and lipoprotein apheresis may be necessary for severe cases, though their use is often limited by factors such as cost, availability, and potential fetal risks. Despite the promise of advanced therapies, their widespread application remains constrained by limited studies and high costs. Thus, a personalized, multidisciplinary approach is essential for optimizing outcomes. This review provides a comprehensive overview of current strategies and evidence-based practices for managing dyslipidemia during pregnancy, emphasizing the balance of maternal and fetal health. Additionally, it discusses the physiological changes in lipid metabolism during pregnancy and their implications, particularly for women with inherited forms of dyslipidemia.
Collapse
Affiliation(s)
- Elena Formisano
- Department of Internal Medicine, University of Genoa, 16132 Genoa, Italy
- Dietetics and Clinical Nutrition Unit, IRCCS Policlinic Hospital San Martino, 16132 Genoa, Italy
| | - Elisa Proietti
- Department of Internal Medicine, University of Genoa, 16132 Genoa, Italy
| | - Giuseppina Perrone
- Department of Maternal and Child Health and Urological Sciences, Umberto I Hospital, "Sapienza" University of Rome, 00161 Rome, Italy
| | - Valentina Demarco
- Department of Maternal and Child Health and Urological Sciences, Umberto I Hospital, "Sapienza" University of Rome, 00161 Rome, Italy
| | - Paola Galoppi
- Department of Maternal and Child Health and Urological Sciences, Umberto I Hospital, "Sapienza" University of Rome, 00161 Rome, Italy
| | - Claudia Stefanutti
- Department of Molecular Medicine, Extracorporeal Therapeutic Techniques Unit, Lipid Clinic and Atherosclerosis Prevention Centre, Regional Centre for Rare Diseases, Immunohematology and Transfusion Medicine, Umberto I Hospital, "Sapienza" University of Rome, 00161 Rome, Italy
| | - Livia Pisciotta
- Department of Internal Medicine, University of Genoa, 16132 Genoa, Italy
- Dietetics and Clinical Nutrition Unit, IRCCS Policlinic Hospital San Martino, 16132 Genoa, Italy
| |
Collapse
|
3
|
Schatoff D, Jung IY, Goldberg IJ. Lipid Disorders and Pregnancy. Endocrinol Metab Clin North Am 2024; 53:483-495. [PMID: 39084821 DOI: 10.1016/j.ecl.2024.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/02/2024]
Abstract
Practicing endocrinologists are likely to confront 2 major issues that occur with dyslipidemias during pregnancy. The most dramatic is the development of severe hypertriglyceridemia leading to acute pancreatitis. The second is the approach to treatment of familial hypercholesterolemia, a common genetic disorder. This article reviews the normal physiology and the pathophysiology of lipoproteins that occurs with pregnancy and then discusses the approaches to prevention and/or treatment of dyslipidemia in pregnancy with a focus on lifestyle and acceptable drug therapies.
Collapse
Affiliation(s)
- Daria Schatoff
- New York University Grossman School of Medicine, New York, USA
| | - Irene Y Jung
- New York University Grossman School of Medicine, New York, USA
| | - Ira J Goldberg
- Department of Medicine, New York University Grossman School of Medicine, New York, USA; Holman Division of Endocrinology, Diabetes & Metabolism, New York University Grossman School of Medicine, New York, USA.
| |
Collapse
|
4
|
Baracchi A, Piani F, Degli Esposti D, Agnoletti D, Borghi C, D'Addato S. When pregnancy-associated hypertriglyceridemia goes above and beyond the risk of pancreatitis. Intern Emerg Med 2024; 19:477-481. [PMID: 37468772 DOI: 10.1007/s11739-023-03378-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 06/21/2023] [Indexed: 07/21/2023]
Affiliation(s)
- Alessandro Baracchi
- Hypertension and Cardiovascular Risk Research Center, Medical and Surgical Sciences Dept., Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Federica Piani
- Hypertension and Cardiovascular Risk Research Center, Medical and Surgical Sciences Dept., Alma Mater Studiorum University of Bologna, Bologna, Italy.
- Cardiovascular Medicine Unit, Heart, Chest and Vascular Dept., IRCCS Azienda-Ospedaliero Universitaria Di Bologna, Bologna, Italy.
| | - Daniela Degli Esposti
- Cardiovascular Medicine Unit, Heart, Chest and Vascular Dept., IRCCS Azienda-Ospedaliero Universitaria Di Bologna, Bologna, Italy
| | - Davide Agnoletti
- Hypertension and Cardiovascular Risk Research Center, Medical and Surgical Sciences Dept., Alma Mater Studiorum University of Bologna, Bologna, Italy
- Cardiovascular Medicine Unit, Heart, Chest and Vascular Dept., IRCCS Azienda-Ospedaliero Universitaria Di Bologna, Bologna, Italy
| | - Claudio Borghi
- Hypertension and Cardiovascular Risk Research Center, Medical and Surgical Sciences Dept., Alma Mater Studiorum University of Bologna, Bologna, Italy
- Cardiovascular Medicine Unit, Heart, Chest and Vascular Dept., IRCCS Azienda-Ospedaliero Universitaria Di Bologna, Bologna, Italy
| | - Sergio D'Addato
- Hypertension and Cardiovascular Risk Research Center, Medical and Surgical Sciences Dept., Alma Mater Studiorum University of Bologna, Bologna, Italy
- Cardiovascular Medicine Unit, Heart, Chest and Vascular Dept., IRCCS Azienda-Ospedaliero Universitaria Di Bologna, Bologna, Italy
| |
Collapse
|
5
|
Diagnosis and Management of Acute Pancreatitis in Pregnancy. Clin Obstet Gynecol 2023; 66:237-249. [PMID: 36044625 DOI: 10.1097/grf.0000000000000737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Acute pancreatitis is rare in pregnancy; however, the associated morbidity and mortality make prompt diagnosis and appropriate management essential. 1,2 Although most cases are mild and improve with limited interventions, severe cases require a multidisciplinary approach in a critical care setting. The main principles of management include identification of an etiology to guide therapy, fluid resuscitation, electrolyte repletion, early nutritional support, and pain management. Antibiotics are not indicated for prophylaxis and should be reserved for cases with a suspected infectious process. Surgical management is indicated in select cases. Management in pregnant patients has few differences which are outlined below.
Collapse
|
6
|
Okazaki H, Gotoda T, Ogura M, Ishibashi S, Inagaki K, Daida H, Hayashi T, Hori M, Masuda D, Matsuki K, Yokoyama S, Harada-Shiba M. Current Diagnosis and Management of Primary Chylomicronemia. J Atheroscler Thromb 2021; 28:883-904. [PMID: 33980761 PMCID: PMC8532063 DOI: 10.5551/jat.rv17054] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Hiroaki Okazaki
- Department of Diabetes and Metabolic Diseases, Graduate School of Medicine, The University of Tokyo
| | - Takanari Gotoda
- Department of Metabolic Biochemistry, Faculty of Medicine, Kyorin University
| | - Masatsune Ogura
- Department of Molecular Innovation in Lipidology, National Cerebral and Cardiovascular Center Research Institute
| | - Shun Ishibashi
- Division of Endocrinology and Metabolism, Department of Internal Medicine, School of Medicine, Jichi Medical University
| | - Kyoko Inagaki
- Division of Diabetes, Endocrinology, and Metabolism, Department of Medicine, Nippon Medical School
| | - Hiroyuki Daida
- Faculty of Health Science, Juntendo University, Juntendo University Graduate School of Medicine
| | - Toshio Hayashi
- School of Health Sciences, Nagoya University Graduate School of Medicine
| | - Mika Hori
- Department of Endocrinology, Research Institute of Environmental Medicine, Nagoya University
| | - Daisaku Masuda
- Department of Cardiology, Health Care Center, Rinku Innovation Center for Wellness Care and Activities (RICWA), Rinku General Medical Center
| | - Kota Matsuki
- Department of Endocrinology and Metabolism, Hirosaki University Graduate School of Medicine
| | | | - Mariko Harada-Shiba
- Department of Molecular Pathogenesis, National Cerebral and Cardiovascular Center Research Institute
| | | |
Collapse
|
7
|
AYDEMİR E, ÇETİN SB, AYDOĞAN ÜNSAL Y, ATEŞ C, CANDER S, ÖZ GÜL Ö, ERTÜRK E, ERSOY C. A Case of very Severe Hypertriglyceridemia during Pregnancy. TURKISH JOURNAL OF INTERNAL MEDICINE 2021. [DOI: 10.46310/tjim.882279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
|
8
|
Kleess LE, Janicic N. SEVERE HYPERTRIGLYCERIDEMIA IN PREGNANCY: A CASE REPORT AND REVIEW OF THE LITERATURE. AACE Clin Case Rep 2018; 5:e99-e103. [PMID: 31967011 DOI: 10.4158/accr-2018-0168] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 09/11/2018] [Indexed: 12/18/2022] Open
Abstract
Objective Severe gestational hypertriglyceridemia is a rare disease, and there are no published guidelines to assist the clinician in management. However, due to the elevations in lipids that occur during pregnancy, this condition is encountered in clinical practice and presents a therapeutic dilemma. We report the successful management and treatment of a patient with severe gestational hypertriglyceridemia and conducted a review of the literature regarding treatment modalities. Methods We conducted a search in PubMed from 1990 to 2018 for the following terms: "severe hypertriglyceridemia in pregnancy;" "management of hypertriglyceridemia in pregnancy;" "apheresis for severe gestational hypertriglyceridemia;" "TPN for severe gestational hypertriglyceridemia;" "insulin for severe gestational hypertriglyceridemia;" and "heparin for treatment of severe hypertriglyceridemia." We then reviewed the literature. Results Given the risks to the mother and fetus of severe hypertriglyceridemia, aggressive therapy should be initiated within a multidisciplinary team. There are multiple treatment modalities, including restrictive diet, various medications such as niacin, fibrates, intravenous heparin, insulin, and apheresis. Choice of treatment will depend on the patient's comorbidities, clinical status, and if there are any associated complications. Conclusion Treatment for severe gestational hypertriglyceridemia should be initiated immediately and aggressively to avoid risk to the mother and infant, including pancreatitis, hyperviscosity syndrome, preeclampsia, fetal death, and preterm labor.
Collapse
|
9
|
Cao S, Dao N, Roloff K, Valenzuela GJ. Pregnancies Complicated by Familial Hypertriglyceridemia: A Case Report. AJP Rep 2018; 8:e362-e364. [PMID: 30591842 PMCID: PMC6306273 DOI: 10.1055/s-0038-1676832] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Accepted: 11/14/2018] [Indexed: 11/26/2022] Open
Abstract
Background Although rare, familial hypertriglyceridemia can cause acute and life-threatening complications in pregnancy. Cases The first patient's pregnancy was complicated by multiple admissions for pancreatitis due to hypertriglyceridemia and noncompliance with gemfibrozil. In her second pregnancy, she was compliant with gemfibrozil and only experienced pancreatitis episodes toward the end of pregnancy. The second patient had diabetes mellitus and familial hypertriglyceridemia. She required multiple hospitalizations for diabetic ketoacidosis secondary to insulin noncompliance. In both pregnancies, she was compliant with gemfibrozil and had no complications related to hypertriglyceridemia. Conclusion Treatment with gemfibrozil in pregnancies complicated by hypertriglyceridemia may prevent complications without adverse maternal or fetal effects and could be considered in treating pregnant patients with severe hypertriglyceridemia. These cases also demonstrate the importance of medication compliance in the prevention of poor outcomes.
Collapse
Affiliation(s)
- Suzanne Cao
- Department of Women's Health, Arrowhead Regional Medical Center, Colton, California
| | - NhuChi Dao
- Department of Women's Health, Arrowhead Regional Medical Center, Colton, California
| | - Kristina Roloff
- Department of Women's Health, Arrowhead Regional Medical Center, Colton, California
| | | |
Collapse
|
10
|
Effect of Two Supplements on Gestational Hypertriglyceridemia: Report of Two Cases. WOMEN’S HEALTH BULLETIN 2017. [DOI: 10.5812/whb.13084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
|
11
|
Wong B, Ooi TC, Keely E. Severe gestational hypertriglyceridemia: A practical approach for clinicians. Obstet Med 2015; 8:158-67. [PMID: 27512474 PMCID: PMC4935053 DOI: 10.1177/1753495x15594082] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Severe gestational hypertriglyceridemia is a potentially life threatening and complex condition to manage, requiring attention to a delicate balance between maternal and fetal needs. During pregnancy, significant alterations to lipid homeostasis occur to ensure transfer of nutrients to the fetus. In women with an underlying genetic predisposition or a secondary exacerbating factor, severe gestational hypertriglyceridemia can arise, leading to devastating complications, including acute pancreatitis. Multidisciplinary care, implementation of a low-fat diet with nutritional support, and institution of a hierarchical therapeutic approach are all crucial to reduce maternal and fetal morbidity. To avoid maternal pancreatitis, close surveillance of triglycerides throughout pregnancy with elective hospitalization for refractory cases is recommended. Careful dietary planning is required to prevent neural and retinal complications from fetal essential fatty acid deficiency. Questions remain about the safety of fibrates and plasmapheresis in pregnancy as well as the optimal timing for induction and delivery of these women.
Collapse
Affiliation(s)
- Bertha Wong
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Division of Endocrinology and Metabolism, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Teik C Ooi
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Division of Endocrinology and Metabolism, The Ottawa Hospital, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Erin Keely
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Division of Endocrinology and Metabolism, The Ottawa Hospital, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| |
Collapse
|
12
|
Severe hypertriglyceridemia induced pancreatitis in pregnancy. Case Rep Obstet Gynecol 2014; 2014:485493. [PMID: 24995138 PMCID: PMC4065762 DOI: 10.1155/2014/485493] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2014] [Revised: 05/01/2014] [Accepted: 05/23/2014] [Indexed: 11/23/2022] Open
Abstract
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.
Collapse
|
13
|
Stefanutti C, Labbadia G, Morozzi C. Severe hypertriglyceridemia-related acute pancreatitis. Ther Apher Dial 2013; 17:130-7. [PMID: 23551669 DOI: 10.1111/1744-9987.12008] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
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.
Collapse
Affiliation(s)
- Claudia Stefanutti
- Department of Immunohematology and Transfusion Medicine,, Extracorporeal Therapeutic Techniques Unit, Rome, Italy.
| | | | | |
Collapse
|
14
|
Berglund L, Brunzell JD, Goldberg AC, Goldberg IJ, Sacks F, Murad MH, Stalenhoef AFH. Evaluation and treatment of hypertriglyceridemia: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 2012; 97:2969-89. [PMID: 22962670 PMCID: PMC3431581 DOI: 10.1210/jc.2011-3213] [Citation(s) in RCA: 534] [Impact Index Per Article: 44.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE The aim was to develop clinical practice guidelines on hypertriglyceridemia. PARTICIPANTS The Task Force included a chair selected by The Endocrine Society Clinical Guidelines Subcommittee (CGS), five additional experts in the field, and a methodologist. The authors received no corporate funding or remuneration. CONSENSUS PROCESS Consensus was guided by systematic reviews of evidence, e-mail discussion, conference calls, and one in-person meeting. The guidelines were reviewed and approved sequentially by The Endocrine Society's CGS and Clinical Affairs Core Committee, members responding to a web posting, and The Endocrine Society Council. At each stage, the Task Force incorporated changes in response to written comments. CONCLUSIONS The Task Force recommends that the diagnosis of hypertriglyceridemia be based on fasting levels, that mild and moderate hypertriglyceridemia (triglycerides of 150-999 mg/dl) be diagnosed to aid in the evaluation of cardiovascular risk, and that severe and very severe hypertriglyceridemia (triglycerides of > 1000 mg/dl) be considered a risk for pancreatitis. The Task Force also recommends that patients with hypertriglyceridemia be evaluated for secondary causes of hyperlipidemia and that subjects with primary hypertriglyceridemia be evaluated for family history of dyslipidemia and cardiovascular disease. The Task Force recommends that the treatment goal in patients with moderate hypertriglyceridemia be a non-high-density lipoprotein cholesterol level in agreement with National Cholesterol Education Program Adult Treatment Panel guidelines. The initial treatment should be lifestyle therapy; a combination of diet modification and drug therapy may also be considered. In patients with severe or very severe hypertriglyceridemia, a fibrate should be used as a first-line agent.
Collapse
Affiliation(s)
- Lars Berglund
- University of California, Davis, Sacramento, California 95817, USA
| | | | | | | | | | | | | | | |
Collapse
|
15
|
Nasi M, Pinti M, Chiesa E, Fiore S, Manzini S, Del Giovane C, D'Amico R, Palai N, Campatelli C, Sabbatini F, Roccio M, Tibaldi C, Masuelli G, Mussini C, Ferrazzi E, d'Arminio Monforte A, Cossarizza A. Decreased mitochondrial DNA content in subcutaneous fat from HIV-infected women taking antiretroviral therapy as measured at delivery. Antivir Ther 2011; 16:365-72. [PMID: 21555819 DOI: 10.3851/imp1764] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Increasing numbers of pregnant HIV-positive women are receiving combination antiretroviral regimens for preventing mother-to-child virus transmission or for treating the infection itself. Several studies have demonstrated that nucleoside reverse transcriptase inhibitors (NRTIs) induce mitochondrial toxicity by several mechanisms, including depletion of mitochondrial DNA (mtDNA). By the quantification of mtDNA levels, we studied mitochondrial toxicity in HIV-positive women at delivery and the possible correlations with antiretroviral regimens, viroimmunological and metabolic parameters. METHODS We analysed 68 HIV-positive women enrolled in the Italian Prospective Cohort Study on Efficacy and Toxicity of Antiretroviral in Pregnancy (TARGET Study); all were taking ≥1 NRTI. We quantified mtDNA copies per cell in subcutaneous fat samples collected during delivery. At the 3rd, 6th and 9th month of pregnancy, we collected data concerning CD4(+) T-cell count, plasma HIV RNA, total and high-density lipoprotein (HDL) cholesterol, fasting plasma glucose and triglycerides. As a control, we analysed mtDNA levels in abdominal subcutaneous fat samples from 23 HIV-seronegative women at delivery. RESULTS mtDNA content was significantly lower in HIV-infected women when compared with HIV-negative controls. mtDNA content varied independently from viroimmunological, lipid and glucose parameters at the different months, with the exceptions of triglycerides at the 9th month and of HDL at the 6th month of pregnancy. CONCLUSIONS In subcutaneous tissue from women taking NRTI-based antiretroviral regimens, we observed a significant decrease of mtDNA content, compared with uninfected women not on antiviral treatment. Moreover, a significant correlation was noted between mtDNA content and HDL cholesterol and triglycerides.
Collapse
Affiliation(s)
- Milena Nasi
- Department of Biomedical Sciences, Section of General Pathology, University of Modena and Reggio Emilia, Italy
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
16
|
Ihimoyan A, Chelimilla H, Kalakada N, Dev A, Kumbum K. Hypertriglyceridemia Induced Pancreatitis in a Non-Diabetic Pregnant Patient Requiring the Use of Total Parenteral Nutrition. Gastroenterology Res 2011; 4:88-91. [PMID: 27942321 PMCID: PMC5139761 DOI: 10.4021/gr299w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/21/2011] [Indexed: 11/03/2022] Open
Abstract
Hypertriglyceridemia induced pancreatitis in pregnancy is established and has been widely reported. However there are very scanty reports of cases involving the use of total parenteral nutrition. We report the case of a 37-year-old gravida 3, para 2 woman at 34 weeks of gestation who presented with one day of severe epigastric pain radiating to the back, nausea and bilious vomiting caused by pancreatitis induced by hypertriglyceridemia. Her initial serum triglyceride, amylase and lipase concentration were 6,552 mg/dl, 314 U/L and 537 U/L respectively. She initially received intravenous fluids and insulin with reduction of serum triglyceride levels to 583 mg/dl on the fifth day of admission. However attempts to refeed the patient with solid food resulted in induction of hypertriglyceridemia and relapse of pancreatitis. Lipid free total parenteral nutrition was commenced in the third week of admission and lead to a better control of triglyciderides and resolution of pancreatitis until delivery of a full term healthy neonate.
Collapse
Affiliation(s)
- Ariyo Ihimoyan
- Division of Gastroenterology, Bronx Lebanon Hospital Center, Bronx, New York 10457, USA
| | - Haritha Chelimilla
- Division of Gastroenterology, Bronx Lebanon Hospital Center, Bronx, New York 10457, USA
| | - Nirisha Kalakada
- Department of Medicine, Bronx Lebanon Hospital Center, Bronx, New York 10457, USA
| | - Anil Dev
- Division of Gastroenterology, Bronx Lebanon Hospital Center, Bronx, New York 10457, USA
| | - Kavitha Kumbum
- Division of Gastroenterology, Bronx Lebanon Hospital Center, Bronx, New York 10457, USA
| |
Collapse
|
17
|
Abstract
Gemfibrozil is long known for its ability to reduce the level of triglycerides in the blood circulation and to decrease the risk of hyperlipidemia. However, a number of recent studies reveal that apart from its lipid-lowering effects, gemfibrozil can also regulate many other signaling pathways responsible for inflammation, switching of T-helper cells, cell-to-cell contact, migration, and oxidative stress. In this review, we have made an honest attempt to analyze various biological activities of gemfibrozil and associated mechanisms that may help to consider this drug for different human disorders as primary or adjunct therapy.
Collapse
Affiliation(s)
- Avik Roy
- Department of Neurological Sciences, Rush University Medical Center, Chicago, Illinois 60612, USA
| | | |
Collapse
|
18
|
Severe hypertriglyceridemia complicating pregnancy, management by dietary intervention and ω-3 fatty acid supplementation. Nutrition 2009; 25:1098-9. [DOI: 10.1016/j.nut.2009.05.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2009] [Accepted: 05/06/2009] [Indexed: 11/17/2022]
|
19
|
Tsuang W, Navaneethan U, Ruiz L, Palascak JB, Gelrud A. Hypertriglyceridemic pancreatitis: presentation and management. Am J Gastroenterol 2009; 104:984-91. [PMID: 19293788 DOI: 10.1038/ajg.2009.27] [Citation(s) in RCA: 266] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Hypertriglyceridemia (HTG) is reported to cause 1-4% of acute pancreatitis (AP) episodes. HTG is also implicated in more than half of gestational pancreatitis cases. Disorders of lipoprotein metabolism are conventionally divided into primary (genetic) and secondary causes, including diabetes, hypothyroidism, and obesity. Serum triglyceride (TG) levels above 1,000 mg/dl are usually considered necessary to ascribe causation for AP. The mechanism for hypertriglyceridemic pancreatitis (HTGP) is postulated to involve hydrolysis of TG by pancreatic lipase and release of free fatty acids that induce free radical damage. Multiple small studies on HTGP management have evaluated the use of insulin, heparin, or both. Many series have also reported use of apheresis to reduce TG levels. Subsequent control of HTG with dietary restrictions, antihyperlipidemic agents, and even regular apheresis has been shown anecdotally in case series to prevent future episodes of AP. However, large multicenter studies are needed to optimize future management guidelines for patients with HTGP.
Collapse
Affiliation(s)
- Wayne Tsuang
- Department of Internal Medicine, University of Cincinnati Medical Center, Cincinnati, Ohio, USA
| | | | | | | | | |
Collapse
|
20
|
Huissoud C, Robert JM, Bakrin N, Rudigoz RC, Levrat A. [Severe gestational hypertriglyceridemia: related complications and management]. ACTA ACUST UNITED AC 2008; 37:517-20. [PMID: 18313234 DOI: 10.1016/j.jgyn.2007.12.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2007] [Revised: 12/14/2007] [Accepted: 12/27/2007] [Indexed: 10/22/2022]
Abstract
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.
Collapse
Affiliation(s)
- C Huissoud
- Service de gynécologie-obstétrique, hospices civils de Lyon, université Claude-Bernard-Lyon-I, hôpital de la Croix-Rousse, 93, Grande rue de la Croix-Rousse, 69004 Lyon cedex, France.
| | | | | | | | | |
Collapse
|
21
|
Abu Musa AA, Usta IM, Rechdan JB, Nassar AH. Recurrent hypertriglyceridemia-induced pancreatitis in pregnancy: a management dilemma. Pancreas 2006; 32:227-8. [PMID: 16552349 DOI: 10.1097/01.mpa.0000202943.70708.2d] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
|
22
|
Loh JA, Rickels MR, Williams J, Iqbal N. Total Parenteral Nutrition in Management of Hyperlipidemic Pancreatitis During Pregnancy. Endocr Pract 2005; 11:325-30. [PMID: 16191493 DOI: 10.4158/ep.11.5.325] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To describe a case of severe gestational hyperlipidemic pancreatitis successfully managed with minimal-lipid-containing parenteral nutrition (PN) followed by a minimal-fat diet, which resulted in delivery of a healthy full-term neonate. METHODS We present the case of a young woman with gestational hyperlipidemic pancreatitis whose management included the use of PN during pregnancy. In addition, we review the literature pertaining to the management of hyperlipidemic pancreatitis during pregnancy and discuss the role for PN. RESULTS A 32-year-old gravida 2, para 1 woman at 27 weeks 3 days of gestation presented with 1 day of nausea, bilious emesis, and severe abdominal pain caused by pancreatitis attributable to hypertriglyceridemia. Her initial serum triglyceride concentration was 9,450 mg/dL. She received fluids intravenously and minimal-lipid PN until resolution of her symptoms. The serum triglyceride level remained less than 850 mg/dL during administration of PN. She subsequently tolerated a minimal-fat diet, while the serum triglyceride level was maintained at less than 1,400 mg/dL, until delivery of a full-term, healthy neonate. CONCLUSION In severe gestational hyperlipidemic pancreatitis, PN offers a safe and flexible treatment option by providing pancreatic rest and controlling serum triglyceride concentrations while maintaining fetal and maternal nutritional support.
Collapse
Affiliation(s)
- Jennifer A Loh
- Department of Medicine, Division of Internal Medicine, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania 19104, USA
| | | | | | | |
Collapse
|