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Logan S, Randhawa HK, Selvaratnam R. Unification of Triglyceride Limits for Hypertriglyceridemia. Can J Cardiol 2024; 40:355-356. [PMID: 37844665 DOI: 10.1016/j.cjca.2023.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Accepted: 10/03/2023] [Indexed: 10/18/2023] Open
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2
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Yuan C, Xu Y, Lu G, Hu Y, Mao W, Ke L, Tong Z, Xia Y, Ma S, Dong X, Xian X, Wu X, Liu G, Li B, Li W. AAV-mediated hepatic LPL expression ameliorates severe hypertriglyceridemia and acute pancreatitis in Gpihbp1 deficient mice and rats. Mol Ther 2024; 32:59-73. [PMID: 37974401 PMCID: PMC10787151 DOI: 10.1016/j.ymthe.2023.11.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 09/13/2023] [Accepted: 11/13/2023] [Indexed: 11/19/2023] Open
Abstract
GPIHBP1 plays an important role in the hydrolysis of triglyceride (TG) lipoproteins by lipoprotein lipases (LPLs). However, Gpihbp1 knockout mice did not develop hypertriglyceridemia (HTG) during the suckling period but developed severe HTG after weaning on a chow diet. It has been postulated that LPL expression in the liver of suckling mice may be involved. To determine whether hepatic LPL expression could correct severe HTG in Gpihbp1 deficiency, liver-targeted LPL expression was achieved via intravenous administration of the adeno-associated virus (AAV)-human LPL gene, and the effects of AAV-LPL on HTG and HTG-related acute pancreatitis (HTG-AP) were observed. Suckling Gpihbp1-/- mice with high hepatic LPL expression did not develop HTG, whereas Gpihbp1-/- rat pups without hepatic LPL expression developed severe HTG. AAV-mediated liver-targeted LPL expression dose-dependently decreased plasma TG levels in Gpihbp1-/- mice and rats, increased post-heparin plasma LPL mass and activity, decreased mortality in Gpihbp1-/- rat pups, and reduced the susceptibility and severity of both Gpihbp1-/- animals to HTG-AP. However, the muscle expression of AAV-LPL had no significant effect on HTG. Targeted expression of LPL in the liver showed no obvious adverse reactions. Thus, liver-targeted LPL expression may be a new therapeutic approach for HTG-AP caused by GPIHBP1 deficiency.
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Affiliation(s)
- Chenchen Yuan
- Department of Critical Care Medicine, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing 210008, China
| | - Yao Xu
- Department of Critical Care Medicine, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing 210008, China
| | - Guotao Lu
- Department of Critical Care Medicine, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing 210008, China
| | - Yuepeng Hu
- Department of Critical Care Medicine, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing 210008, China
| | - Wenjian Mao
- Department of Critical Care Medicine, Jinling Hospital, Nanjing Medical University, Nanjing 210008, China
| | - Lu Ke
- Department of Critical Care Medicine, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing 210008, China
| | - Zhihui Tong
- Department of Critical Care Medicine, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing 210008, China
| | - Yan Xia
- GeneCradle Therapeutics Inc, Beijing 100176, China
| | - Sisi Ma
- GeneCradle Therapeutics Inc, Beijing 100176, China
| | - Xiaoyan Dong
- GeneCradle Therapeutics Inc, Beijing 100176, China
| | - Xunde Xian
- Institute of Cardiovascular Sciences, State Key Laboratory of Vascular Homeostasis and Remodeling, School of Basic Medical Sciences, Peking University, Beijing 100191, China
| | - Xiaobing Wu
- GeneCradle Therapeutics Inc, Beijing 100176, China
| | - George Liu
- GeneCradle Therapeutics Inc, Beijing 100176, China.
| | - Baiqiang Li
- Department of Critical Care Medicine, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing 210008, China.
| | - Weiqin Li
- Department of Critical Care Medicine, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing 210008, China.
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Paul S, Nirmal G, Chadha V, Sharma R, Kochar I, Jerath N, Vohra R, Kharya G. Sirolimus-induced Hypertriglyceridemia Leads to Acute Pancreatitis and Diabetic Ketoacidosis Post Stem Cell Transplant for Sickle Cell Disease. J Pediatr Hematol Oncol 2024; 46:e91-e93. [PMID: 38019672 DOI: 10.1097/mph.0000000000002793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 10/18/2023] [Indexed: 12/01/2023]
Abstract
Sirolimus (mammalian target of rapamycin inhibitor) is a potent immunosuppressive agent, used in patients receiving hematopoietic stem cell transplant (HSCT) for Graft vs Host disease prophylaxis. Compared to calcineurin inhibitors, sirolimus has no neurotoxicity or nephrotoxicity, but sirolimus causes dose-dependent thrombocytopenia, leukopenia, delayed wound healing, hyperlipidemia, and hypertriglyceridemia. Here we report a case of acute pancreatitis and diabetic ketoacidosis in a patient with sickle cell disease post haploidentical family donor HSCT which was managed conservatively without plasmapheresis. Based on our review of the literature, this is the first reported case of developing acute pancreatitis as an adverse effect of sirolimus-induced hypertriglyceridemia leading to diabetic ketoacidosis in a recipient of HSCT.
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Affiliation(s)
- Subhasish Paul
- Department of Pediatrics, Centre for Bone Marrow Transplant & Cellular Therapy
| | - Garima Nirmal
- Department of Pediatrics, Centre for Bone Marrow Transplant & Cellular Therapy
| | - Vaibhav Chadha
- Department of Pediatrics, Centre for Bone Marrow Transplant & Cellular Therapy
| | - Rahul Sharma
- Department of Pediatrics, Centre for Bone Marrow Transplant & Cellular Therapy
| | | | - Namith Jerath
- Pediatrics, Indraprastha Apollo Hospital, Delhi, India
| | - Rohit Vohra
- Pediatrics, Indraprastha Apollo Hospital, Delhi, India
| | - Gaurav Kharya
- Department of Pediatrics, Centre for Bone Marrow Transplant & Cellular Therapy
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Akivis Y, Alkaissi H, McFarlane SI, Bukharovich I. The Role of Triglycerides in Atherosclerosis: Recent Pathophysiologic Insights and Therapeutic Implications. Curr Cardiol Rev 2024; 20:39-49. [PMID: 38288833 DOI: 10.2174/011573403x272750240109052319] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Revised: 12/13/2023] [Accepted: 12/30/2023] [Indexed: 04/30/2024] Open
Abstract
Triglycerides have long been recognized as a cardiovascular disease risk factor. However, their precise role in atherosclerosis and potential utility as a therapeutic target remains debated topics. This review aims to shed light on these aspects by exploring the complex relationship between triglycerides and atherosclerosis from pathophysiological and pharmacological perspectives. Triglycerides, primarily carried by chylomicrons and very low-density lipoproteins, play an essential role in energy storage and utilization. Dysregulation of triglyceride homeostasis and triglyceride- rich lipoproteins metabolism often leads to hypertriglyceridemia and subsequently increases atherosclerosis risk. Triglyceride-rich lipoproteins remnants interact with arterial wall endothelial cells, get retained in the subendothelial space, and elicit inflammatory responses, thereby accelerating atherogenesis. Despite the clear association between high triglyceride levels and increased cardiovascular disease risk, intervention trials targeting triglyceride reduction have produced mixed results. We discuss a range of triglyceride-lowering agents, from fibrates to omega-3 fatty acids, with a focus on their mechanism of action, efficacy, and major clinical trial outcomes. Notably, the role of newer agents, such as angiopoietin-like protein 3 and apolipoprotein C3 inhibitors, is also explored. We highlight the challenges and controversies, including the ongoing debate on the causal role of triglyceride in atherosclerosis and the discordant outcomes of recent clinical trials. The potential confounding effects of associated risk factors, such as elevated apolipoprotein B, insulin resistance, and metabolic syndrome, are considered. In conclusion, this review underscores the importance of a nuanced approach to understanding the role of triglycerides in atherosclerosis and their potential as a therapeutic target. Further research is needed to unravel the complex interplay between triglycerides, triglyceride-rich lipoproteins, and associated factors in atherosclerosis pathogenesis and refine triglyceride-targeted therapeutic strategies.
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Affiliation(s)
- Yonatan Akivis
- Department of Medicine, SUNY Downstate Health Sciences University, Brooklyn, NY, 11203, USA
| | - Hussam Alkaissi
- Department of Medicine, SUNY Downstate Health Sciences University, Brooklyn, NY, 11203, USA
| | - Samy I McFarlane
- Department of Medicine, SUNY Downstate Health Sciences University, Brooklyn, NY, 11203, USA
| | - Inna Bukharovich
- Division of Cardiology, Department of Medicine, NYC Health and & Hospitals, Kings County, Brooklyn, NY, 11203, USA
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Song J, Cui Y, Song J, Lee C, Wu M, Chen H. Evaluation of the Needs and Experiences of Patients with Hypertriglyceridemia: Social Media Listening Infosurveillance Study. J Med Internet Res 2023; 25:e44610. [PMID: 38113100 PMCID: PMC10762621 DOI: 10.2196/44610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Revised: 07/13/2023] [Accepted: 09/19/2023] [Indexed: 12/21/2023] Open
Abstract
BACKGROUND Hypertriglyceridemia is a risk factor for cardiovascular diseases. Internet usage in China is increasing, giving rise to large-scale data sources, especially to access, disseminate, and discuss medical information. Social media listening (SML) is a new approach to analyze and monitor online discussions related to various health-related topics in diverse diseases, which can generate insights into users' experiences and expectations. However, to date, no studies have evaluated the utility of SML to understand patients' cognizance and expectations pertaining to the management of hypertriglyceridemia. OBJECTIVE The aim of this study was to utilize SML to explore the disease cognition level of patients with hypertriglyceridemia, choice of intervention measures, and the status quo of online consultations and question-and-answer (Q&A) search platforms. METHODS An infosurveillance study was conducted wherein a disease-specific comprehensive search was performed between 2004 and 2020 in Q&A search and online consultation platforms. Predefined single and combined keywords related to hypertriglyceridemia were used in the search, including disease, symptoms, diagnosis, and treatment indicators; lifestyle interventions; and therapeutic agents. The search output was aggregated using an aggregator tool and evaluated. RESULTS Disease-specific consultation data (n=69,845) and corresponding response data (n=111,763) were analyzed from 20 data sources (6 Q&A search platforms and 14 online consultation platforms). Doctors from inland areas had relatively high voice volumes and appear to exert a substantial influence on these platforms. Patients with hypertriglyceridemia engaging on the internet have an average level of cognition about the disease and its intervention measures. However, a strong demand for the concept of the disease and "how to treat it" was observed. More emphasis on the persistence of the disease and the safety of medications was observed. Young patients have a lower willingness for drug interventions, whereas patients with severe hypertriglyceridemia have a clearer intention to use drug intervention and few patients have a strong willingness for the use of traditional Chinese medicine. CONCLUSIONS Findings from this disease-specific SML study revealed that patients with hypertriglyceridemia in China actively seek information from both online Q&A search and consultation platforms. However, the integrity of internet doctors' suggestions on lifestyle interventions and the accuracy of drug intervention recommendations still need to be improved. Further, a combined prospective qualitative study with SML is required for added rigor and confirmation of the relevance of the findings.
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Affiliation(s)
- Junxian Song
- Beijing Key Laboratory of Early Prediction and Intervention of Acute Myocardial Infarction, Department of Cardiology, Center for Cardiovascular Translational Research, Peking University People's Hospital, Beijing, China
| | - Yuxia Cui
- Beijing Key Laboratory of Early Prediction and Intervention of Acute Myocardial Infarction, Department of Cardiology, Center for Cardiovascular Translational Research, Peking University People's Hospital, Beijing, China
| | - Jing Song
- Beijing Key Laboratory of Early Prediction and Intervention of Acute Myocardial Infarction, Department of Cardiology, Center for Cardiovascular Translational Research, Peking University People's Hospital, Beijing, China
| | - Chongyou Lee
- Beijing Key Laboratory of Early Prediction and Intervention of Acute Myocardial Infarction, Department of Cardiology, Center for Cardiovascular Translational Research, Peking University People's Hospital, Beijing, China
| | - Manyan Wu
- Beijing Key Laboratory of Early Prediction and Intervention of Acute Myocardial Infarction, Department of Cardiology, Center for Cardiovascular Translational Research, Peking University People's Hospital, Beijing, China
| | - Hong Chen
- Beijing Key Laboratory of Early Prediction and Intervention of Acute Myocardial Infarction, Department of Cardiology, Center for Cardiovascular Translational Research, Peking University People's Hospital, Beijing, China
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Freedman S, de-Madaria E, Bruckert E, Löhr M, Rebours V, Jandhyala R. Observed consensus on research priorities for the hypertriglyceridemia patient registry. Curr Med Res Opin 2023; 39:1629-1635. [PMID: 37428680 DOI: 10.1080/03007995.2023.2235153] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 07/05/2023] [Accepted: 07/07/2023] [Indexed: 07/12/2023]
Abstract
BACKGROUND Priority setting in health research has been described as essential due to disparities within and between countries and populations. Commercial benefits to the pharmaceutical industry may increase the generation and use of regulatory Real-World Evidence which has recently been reported in the literature. Research must be steered by valuable priorities. This study's objective is to identify key gaps in the knowledge of triglyceride-induced acute pancreatitis by generating a list of potential research priorities for a Hypertriglyceridemia Patient Registry. METHOD The Jandhyala Method was used to observe the consensus of expert opinion from ten specialist clinicians in the treatment of triglyceride-induced acute pancreatitis across the US and EU. RESULTS Ten participants completed the consensus round of the Jandhyala method and generated 38 unique items which they all agreed with. The items were included in the generation of research priorities for a hypertriglyceridemia patient registry and presented a novel application of the Jandhyala method for the development of research questions, in aid of the validation of a core dataset. CONCLUSION The TG-IAP core dataset and research priorities combined can develop a globally harmonized framework where TG-IAP patients can be observed simultaneously using the same set of indicators. This will increase knowledge of the disease and facilitate higher-quality research by addressing issues related to incomplete data sets in observational studies. Furthermore, validation of new tools will be enabled, and diagnosis and monitoring will be improved as well as the detection of changes in disease severity and subsequent disease progression, improving the management of patients with TG-IAP overall. This will inform personalized patient management plans and improve patient outcomes along with their quality of life.
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Affiliation(s)
- Steve Freedman
- The Pancreas Center, Beth Israel Deaconess Medical Center (BIDMC), Boston, MA, USA
| | - Enrique de-Madaria
- Gastroenterology Department, Dr. Balmis General University Hospital; Department of Clinical Medicine, Miguel Hernández University, Isabial, Spain
| | - Eric Bruckert
- Endocrinology and prevention of cardiovascular disease department in Pitié-Salpêtrière Hospital, Paris, France
| | - Matthias Löhr
- Pancreas Cancer Research Lab, Department of Clinical Science, Intervention and Technology, (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Vinciane Rebours
- Pancreatology and Digestive Oncology Department, Beaujon Hospital, AP-HP, Clichy, Paris-Cité University, Paris, France
| | - Ravi Jandhyala
- Medialis Ltd, England, UK
- Centre for Pharmaceutical Medicine Research, King's College University, London, UK
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Abstract
In this issue of NEJM Evidence, Gaudet et al.1 report on safety and efficacy of a strategy targeting apolipoprotein C-III (APOC3) using a silencing ribonucleic acid (RNA; ARO-APOC3). In a phase I trial comprising 52 healthy volunteers (triglycerides [TG], >80 mg/dl), 40 patients with hypertriglyceridemia (TG, >300 mg/dl), and 20 patients with chylomicronemia (TG, >880 mg/dl), ARO-APOC3 or placebo was administered subcutaneously either once or twice, with doses given on days 1 and 29. The primary goal was to examine the safety of ARO-APOC3. Injection site reactions were the most commonly observed adverse clinical event; no adverse effects led to discontinuation of the study drug.
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Affiliation(s)
| | - Erik S G Stroes
- Department of Vascular Medicine, Amsterdam University Medical Center, Amsterdam
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Freedman S, de-Madaria E, Bruckert E, Löhr M, Rebours V, Jandhyala R. A protocol for an international, multicenter, prospective, non-interventional observational registry for patients with hypertriglyceridemia. Curr Med Res Opin 2023; 39:1663-1670. [PMID: 37665595 DOI: 10.1080/03007995.2023.2255129] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 08/18/2023] [Accepted: 08/31/2023] [Indexed: 09/05/2023]
Abstract
BACKGROUND In the study on triglyceride-induced pancreatitis (TG-IAP), a core clinical dataset using the Jandhyala method was developed to collect the minimum amount of information for each patient presenting with TG-IAP globally. This approach offered a unified framework for observing multiple populations of TG-IAP patients using the same set of indicators, resulting in a considerably larger and uniform real-world population. It was understood that when this core dataset is implemented in a patient registry it could address the issue of missing data in observational studies and produce higher-quality research. In this paper, the protocol used to design and implement a patient registry for this core dataset to generate real-world evidence from multiple sites is described. METHOD The study is designed as an international, multicenter, non-interventional, observational registry that will enroll adult patients with hypertriglyceridemia to collect natural history data on the treatment, progression, and long-term outcomes of hypertriglyceridemia-induced acute pancreatitis. Patients with both hypertriglyceridemia and pancreatitis will be invited to participate in the registry at participating hospitals and centers worldwide. DISCUSSION Data from this registry, and others like it, is intended for healthcare providers to optimize clinical decision-making through an enhanced understanding of the variability, progression, and natural history of hypertriglyceridemia as well as the burden of disease. CONCLUSION Global epidemiological data on hypertriglyceridemia and its role in acute pancreatitis is limited. Using real-world evidence, this registry, along with others like it, may help healthcare providers understand the variability, progression, natural history, and burden of the disease, and improve the diagnosis and management of HTG and TG-IAP.
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Affiliation(s)
- Steve Freedman
- The Pancreas Center, Beth Israel Deaconess Medical Center (BIDMC), Boston, Massachusetts, USA
| | - Enrique de-Madaria
- Gastroenterology Department, Dr. Balmis General University Hospital, Department of Clinical Medicine, Miguel Hernández University; ISABIAL, Alicante, Spain
| | - Eric Bruckert
- Endocrinology and Prevention of Cardiovascular Disease Department, Pitié-Salpêtrière Hospital, Paris, France
| | - Matthias Löhr
- Pancreas Cancer Research Lab, Department of Clinical Science, Intervention and Technology, (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Vinciane Rebours
- Pancreatology and Digestive Oncology Department, Beaujon Hospital, AP-HP, Clichy, Paris-Cité University, Paris, France
| | - Ravi Jandhyala
- Medialis Ltd, Milton Keynes, UK
- Centre for Pharmaceutical Medicine Research, King's College University, London, UK
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Wang J, Xia Y, Cao Y, Cai X, Jiang S, Liao Y, Shi M, Luo H, Wang D. Evaluating the efficacy and timing of blood purification modalities in early-stage hyperlipidemic acute pancreatitis treatment. Lipids Health Dis 2023; 22:208. [PMID: 38031159 PMCID: PMC10685498 DOI: 10.1186/s12944-023-01968-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Accepted: 11/11/2023] [Indexed: 12/01/2023] Open
Abstract
Hypertriglyceridemia-induced acute pancreatitis (HTG-AP) is characterized by a violent cytokine storm-driven inflammation and is associated with a predisposition to severe disease. The treatment strategy for HTG-AP consists mainly of conventional symptomatic and lipid-lowering treatments. For early-stage HTG-AP, blood purification (BP) can rapidly and effectively reduce serum triglyceride and inflammatory cytokine levels, block the development of systemic inflammatory response syndrome, and improve patient outcomes. Currently, the primary modalities for BP in patients with HTG-AP include plasma exchange, hemoperfusion, and hemofiltration. When using BP to treat patients with HTG-AP, a comprehensive analysis incorporating the elevated lipid levels and severity of the patient's condition contributes to the selection of different treatment modes. Moreover, the timing of the treatment is also imperative. Early intervention is associated with a better prognosis for patients with HTG-AP requiring lipid-lowering treatment.
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Affiliation(s)
- Jianjun Wang
- Department of Hepatobiliary Surgery, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, 621000, China
| | - Yang Xia
- Department of Neurosurgery, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, 621000, China
| | - Yuan Cao
- Department of Urology, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, 621000, China
| | - Xianfu Cai
- Department of Urology, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, 621000, China
| | - Shichun Jiang
- Department of Urology, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, 621000, China
| | - Yougang Liao
- Department of Urology, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, 621000, China
| | - Mingsong Shi
- Nuclear Medicine Laboratory, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, 621000, China
| | - Huiwen Luo
- Nuclear Medicine Laboratory, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, 621000, China.
| | - Decai Wang
- Department of Urology, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, 621000, China.
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Gabriel K, Hovater K, Gao H, de la Cruz D, Calkins KL, Neu J. Monitoring and management of hypertriglyceridemia in extremely low birth weight neonates receiving intravenous lipid emulsions: A national survey. Early Hum Dev 2023; 186:105872. [PMID: 37862901 DOI: 10.1016/j.earlhumdev.2023.105872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 10/05/2023] [Accepted: 10/06/2023] [Indexed: 10/22/2023]
Abstract
AIM To assess the practice variation of defining, monitoring and managing hypertriglyceridemia (HTG) in extremely low birth weight neonates receiving intravenous lipid emulsions (IVLE). METHODS An 8-question survey created via the web survey site Qualtrics was distributed to neonatologists, neonatal nurse practitioners and fellows within the Section of Neonatal-Perinatal Medicine email directory list in the United States and Canada. Survey results were obtained between August and September 2022. RESULTS There were 249 respondents from approximately 4000 members within the Section of Neonatal-Perinatal Medicine. Responses were documented as a frequency (percentage) with a margin of error of plus or minus 6.2 %. Most respondents were neonatologists, individuals practicing for >10 years and reported a unit-based policy for IVLE initiation and advancement. The definitions of HTG varied among respondents, with the majority (42.7 %) reporting a defining threshold of >200 mg/dL. Nineteen percent of respondents reported not routinely monitoring serum triglyceride concentrations with variable triglyceride monitoring intervals reported by other survey respondents. Regarding elevated triglyceride concentrations, 19.0 % reported decreasing the IVLE rate and checking triglyceride concentrations until normalization; 14.6 % reported IVLE discontinuation and monitoring triglyceride concentrations until normalization; 61.9 % reported using a combination of the above practices; and 4.4 % reported individualized practices for IVLE management with elevated triglyceride concentrations. CONCLUSION This survey demonstrates a high variation in defining, monitoring and managing HTG in extremely low birth weight neonates and emphasizes the need for studies to better guide this practice.
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Affiliation(s)
- Krystina Gabriel
- Department of Pediatrics, Division of Neonatology, University of Florida College of Medicine, 1600 SW Archer Rd, Gainesville, FL 32608, United States.
| | - Kylie Hovater
- Bachelor of Science Student, College of Liberal Arts and Sciences, University of Florida, 102 Griffin-Floyd Hall, Gainesville, FL 32611, United States
| | - Hanzhi Gao
- Research Design and Data Coordinating Center, Clinical and Translational Science Institute, University of Florida, 2004 Mowry Rd, Gainesville, FL 32610, United States
| | - Diomel de la Cruz
- Department of Pediatrics, Division of Neonatology, University of Florida College of Medicine, 1600 SW Archer Rd, Gainesville, FL 32608, United States
| | - Kara L Calkins
- Department of Pediatrics, Division of Neonatology & Developmental Biology, Neonatal Research Center of the UCLA Children's Discovery and Innovation Institute, David Geffen School of Medicine UCLA, 757 Westwood Plaza, Los Angeles, CA 90095, United States
| | - Josef Neu
- Department of Pediatrics, Division of Neonatology, University of Florida College of Medicine, 1600 SW Archer Rd, Gainesville, FL 32608, United States
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11
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Baxter CL, Martin EG, Marwa BM, Pacaud D, Cummings EA. Very severe hypertriglyceridemia complicating pediatric acute lymphoblastic leukemia treatment: a call for management guidelines. J Pediatr Endocrinol Metab 2023; 36:978-982. [PMID: 37403553 DOI: 10.1515/jpem-2023-0122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 06/23/2023] [Indexed: 07/06/2023]
Abstract
OBJECTIVES Severe and very severe hypertriglyceridemia although rare within the pediatric population occur more often among oncology patients, secondary to chemotherapeutic agents. Currently there exists minimal literature to guide management of severe hypertriglyceridemia among pediatric patients. Very-low-fat dietary restriction should be considered over nil per os (NPO) for initial management of severe hypertriglyceridemia in stable pediatric patients. Pediatricians caring for oncology patients must consider chylomicronemia as a potential etiology for presenting symptoms. Pediatric severe hypertriglyceridemia management guidelines are needed as pediatricians must currently rely on anecdotal experiences for management decisions. CASE PRESENTATION Three children receiving treatment for acute lymphoblastic leukemia required hospitalization for very severe hypertriglyceridemia. Management varied among the cases but included: NPO or very-low-fat diet, insulin, intravenous fluids, fibrates, and omega-3 fatty acids. CONCLUSIONS These cases suggest that pediatric severe hypertriglyceridemia management, in the absence of pancreatitis should allow a very-low-fat diet initially rather than NPO followed by pharmacologic therapies.
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Affiliation(s)
- Carly L Baxter
- Department of Pediatrics, University of Ottawa, Ottawa, ON, Canada
| | - Elise G Martin
- Department of Pediatrics, University of Calgary, Calgary, Canada
| | - Bilal M Marwa
- Department of Pediatrics, Dalhousie University, Halifax, Canada
| | - Danièle Pacaud
- Department of Pediatrics, University of Calgary, Calgary, Canada
- Division of Endocrinology & Metabolism, Calgary, Canada
| | - Elizabeth A Cummings
- Department of Pediatrics, Dalhousie University, Halifax, Canada
- Division of Endocrinology & Metabolism, Calgary, Canada
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12
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Thapa S, Allakky A, Turaga A. OCP-driven hypertriglyceridaemia and recurrent acute pancreatitis. BMJ Case Rep 2023; 16:e257067. [PMID: 37798042 PMCID: PMC10565274 DOI: 10.1136/bcr-2023-257067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/07/2023] Open
Abstract
Recurrent acute pancreatitis poses a significant challenge in clinical management. In this case, a young, obese woman with metabolic syndrome presented with her third episode of acute pancreatitis within a span of 4 months. Due to unavailability, plasmapheresis could not be performed, and the patient was managed solely with pharmacological therapy. Initial evaluation revealed abdominal pain, tenderness and elevated laboratory markers. CT scan findings indicated pancreatic and peripancreatic oedema. Further investigations highlighted the presence of hypertriglyceridaemia and hypocalcaemia. As the patient was using oral contraceptive pills (OCP), it was crucial to consider their potential role in causing hypertriglyceridaemia. Consequently, the patient was advised to discontinue OCP use. Despite the lack of plasmapheresis, intensive medical management, including medication and lifestyle modifications, showed positive results. This case underscores the importance of recognising the association between OCP, hypertriglyceridaemia and recurrent pancreatitis in patients with metabolic syndrome.
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Affiliation(s)
- Samriddha Thapa
- Internal Medicine, Lower Bucks Hospital, Bristol, Pennsylvania, USA
| | - Akhil Allakky
- Internal Medicine, Lower Bucks Hospital, Bristol, Pennsylvania, USA
| | - Anjani Turaga
- Surgery, Gandhi Medical College, Secunderabad-Padmarao Nagar, India
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13
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Gubensek J. The role of apheresis and insulin therapy in hypertriglyceridemic acute pancreatitis-a concise review. BMC Gastroenterol 2023; 23:341. [PMID: 37789261 PMCID: PMC10546782 DOI: 10.1186/s12876-023-02957-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 09/12/2023] [Indexed: 10/05/2023] Open
Abstract
Severe hypertriglyceridemia (HTG) is the third most common cause of acute pancreatitis (AP) and is involved in its pathogenesis. Chylomicrons increase blood viscosity and induce ischemia, while free fatty acids induce inflammation and distant organ damage. Conservative treatment options include fasting and insulin; limited evidence shows their comparable efficacy. Plasma exchange might provide more rapid lowering of triglycerides and amelioration of systemic effects of severe AP. Available data from controlled studies show only moderately faster lowering of triglycerides with apheresis (about 70% vs. 50% with conservative treatment within 24 h) and limited data from non-randomized studies show no improvement in clinical outcomes. New evidence is expected soon from ongoing large randomized trials. Until then, insulin may be used in mild HTG-AP and plasma exchange should be considered only in severe HTG-AP, especially if the decline of triglycerides with conservative treatment is slow, and in HTG-AP during pregnancy.
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Affiliation(s)
- Jakob Gubensek
- Department of Nephrology, University Medical Center Ljubljana, Zaloska cesta 7, 1000, Ljubljana, Slovenia.
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia.
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14
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Mufti AK, Ullah N, Hayat M, Khan MA. Hypertriglyceridaemia Induced Pancreatitis Management: A Case Report. J PAK MED ASSOC 2023; 73:1906-1908. [PMID: 37817711 DOI: 10.47391/jpma.7910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/12/2023]
Abstract
Acute pancreatitis results in high morbidity and mortality. Gallstones and alcoholism are considered leading causes of acute pancreatitis. However, increasing prevalence of obesity, diabetes and lifestyle choices has resulted in Hypertriglyceridaemia induced pancreatitis (HTAP) becoming more common. HTAP is said to be more severe than other causes. The treatment options available vary including intravenous (IV) insulin, heparin, plasma exchange, fibrates, niacin, omega three fatty acids and dietary restrictions. This is a case report of a patient presenting with HTAP and the dilemma treating physicians faced in trying to balance the need for urgent treatment with invasiveness of procedure and paucity of evidence.
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Affiliation(s)
| | - Naqeeb Ullah
- Department of Anaesthesia, Northwest General Hospital,Peshawar,Pakistan
| | - Muhammad Hayat
- Department of Anaesthesia, Northwest General Hospital,Peshawar,Pakistan
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15
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Su W, Gao Y, Wang X, Wang D, Feng B, Wu Y, Zheng H, Guo F. Initiation time of double-filtration plasma apheresis affects the risk of persistent organ failure in hypertriglyceridaemia-induced acute pancreatitis: a retrospective study. Sci Rep 2023; 13:13003. [PMID: 37563290 PMCID: PMC10415268 DOI: 10.1038/s41598-023-40287-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 08/08/2023] [Indexed: 08/12/2023] Open
Abstract
The effect of double filtration plasma apheresis (DFPP) on improving the outcomes of patients with hypertriglyceridaemia-induced acute pancreatitis (HTG-AP) remains unclear. The aim of this study was to evaluate the relationship between the initiation time of DFPP and the risk of persistent organ failure (POF) in an HTG-AP cohort in China. We retrospectively evaluated data from HTG-AP patients treated with DFPP 48 h after diagnosis between January 2017 and January 2022. Comparisons across tertiles of the interval from diagnosis to completion of one DFPP session (DTD) were analysed. Logistic regression models and restricted cubic splines (RCS) were used to determine the correlation between the DTD time and risk of POF. Of the 89 patients enrolled, 46 patients (51.69%) suffered POF in the first week of HTG-AP. DFPP was initiated at a median of 17 h after the diagnosis was confirmed. The patients in the highest tertile of DTD time had a significantly increased prevalence of POF. After multivariate adjustment, the logistic regression models found a significant decrease in the odds ratios (OR) of POF from the highest to the lowest DTD tertile (P for trend = 0.006). Moreover, the RCS curves showed a nonlinear relationship in the adjusted OR of POF and DTD time, which remained relatively low and flat during the early DTD time but increased sharply afterwards. Early initiation of DFPP treatment correlates with a reduced risk of POF in HTG-AP patients.
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Affiliation(s)
- Wei Su
- Department of Critical Care Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, 310016, Zhejiang, China
| | - Yuzhen Gao
- Department of Clinical Laboratory, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, 310016, Zhejiang, China
| | - Xiaoling Wang
- Department of Critical Care Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, 310016, Zhejiang, China
| | - Donghai Wang
- Department of Critical Care Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, 310016, Zhejiang, China
| | - Binbin Feng
- Department of Critical Care Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, 310016, Zhejiang, China
| | - Yinshan Wu
- Department of Critical Care Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, 310016, Zhejiang, China
| | - Huijun Zheng
- Department of Critical Care Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, 310016, Zhejiang, China
| | - Feng Guo
- Department of Critical Care Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, 310016, Zhejiang, China.
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16
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Mercure-Corriveau N, O'Brien C, Garg A, Crowe EP, Bloch EM, Tobian AAR. Therapeutic plasma exchange for the treatment of extracorporeal membrane oxygenation dysfunction caused by hypertriglyceridemia. Transfusion 2022; 62:2427-2428. [PMID: 35975478 DOI: 10.1111/trf.17070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 07/18/2022] [Accepted: 07/19/2022] [Indexed: 12/13/2022]
Affiliation(s)
- Nicolas Mercure-Corriveau
- Division of Transfusion Medicine, Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Caitlin O'Brien
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Anjali Garg
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Elizabeth P Crowe
- Division of Transfusion Medicine, Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Evan M Bloch
- Division of Transfusion Medicine, Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Aaron A R Tobian
- Division of Transfusion Medicine, Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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17
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Abstract
Mild to moderate hypertriglyceridemia usually results from multiple small-effect variants in genes that control triglyceride metabolism. Hypertriglyceridemia is a critical component of the metabolic syndrome but can also occur secondary to several other conditions or drugs. Hypertriglyceridemia frequently is associated with an increased risk of cardiovascular disease (CVD). Statins are the mainstay of CVD prevention in hypertriglyceridemia, but eicosapentaenoic ethyl esters should be added in very-high-risk individuals. Although fibrates lower triglyceride levels, their role in CVD prevention remains unclear. Familial partial lipodystrophy is another relatively rare cause, although its true incidence is unknown.
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Affiliation(s)
- Alan Chait
- Division of Metabolism, Endocrinology and Nutrition, Department of Medicine, University of Washington, 850 Republican, Box 358062, Seattle, WA 98109, USA.
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18
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Lin XY, Zeng Y, Zhang ZC, Lin ZH, Chen LC, Ye ZS. Incidence and clinical characteristics of hypertriglyceridemic acute pancreatitis: A retrospective single-center study. World J Gastroenterol 2022; 28:3946-3959. [PMID: 36157550 PMCID: PMC9367230 DOI: 10.3748/wjg.v28.i29.3946] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 04/25/2022] [Accepted: 07/06/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The incidence of hypertriglyceridemic acute pancreatitis (HTG-AP) has increased yearly, but updated population-based estimates on the incidence of HTG-AP are lacking. Reducing serum triglyceride (TG) levels quickly is crucial in the early treatment of HTG-AP. Decreased serum TG levels are treated by non-invasive methods, which include anti-lipidemic agents, heparin, low-molecular weight heparin, and insulin, and invasive methods, such as blood purification including hemoperfusion (HP), plasmapheresis, and continuous renal replacement therapy. However, authoritative guidelines have not been established. Early selection of appropriate treatment is important and beneficial in controlling the development of HTG-AP.
AIM To evaluate the effect between patients treated with intravenous insulin (INS) and HP to guide clinical treatment.
METHODS We retrospectively reviewed 371 patients with HTG-AP enrolled in the Department of Fujian Provincial Hospital form April 2012 to March 2021. The inpatient medical and radiologic records were reviewed to determine clinical features, severity, complications, mortality, recurrence rate, and treatment. Multivariate logistic regression analyses were used to analyze risk factors for severe HTG-AP. Propensity score matching was used to compare the clinical outcomes of INS and HP.
RESULTS A total of 371 patients met the HTG-AP criteria. The incidence of HTG-AP was increased by approximately 2.6 times during the 10 years (8.4% in April 2012-March 2013 and 22.3% in April 2020-March 2021). The highest incidence rate of acute pancreatitis was observed for men in the age group of 30-39 years. The amylase level was elevated in 80.1% of patients but was only three times the normal value in 46.9% of patients. The frequency of severe acute pancreatitis (26.9%), organ failure (31.5%), rate of recurrence (32.9%), and mortality (3.0%) of HTG-AP was high. Improved Marshall score, modified computed tomography severity index score, baseline TG, baseline amylase, C-reactive protein (CRP), albumin, aspartate aminotransferase, low-density lipoprotein cholesterol, urea nitrogen, creatinine, calcium, hemoglobin, free triiodothyronine, admission to intensive care unit, and mortality were significantly different between patients with different grades of severity (P < 0.050). Multivariate logistic regression analysis confirmed that high CRP [P = 0.005, odds ratio (OR) = 1.011, 95%CI: 1.003-1.019], low calcium (P = 0.003, OR = 0.016, 95%CI: 0.001-0.239), and low albumin (P = 0.023, OR = 0.821, 95%CI: 0.693-0.973) were risk factors of severe HTG-AP. After propensity score matching adjusted by sex, age, severity of HTG-AP, and baseline TG, the serum TG significantly decreased in patients treated with INS (P < 0.000) and HP (P < 0.000) within 48 h. However, the clearance rate of TG (57.24 ± 33.70% vs 56.38 ± 33.61%, P = 0.927) and length of stay (13.04 ± 7.92 d vs 12.35 ± 6.40 d, P = 0.730) did not differ between the two groups.
CONCLUSION The incidence of HTG-AP exhibited a significant increase, remarkable severity, and recurrent trend. Patients with mild and moderately severe acute pancreatitis can be treated effectively with INS safely and effectively without HP.
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Affiliation(s)
- Xue-Yan Lin
- Department of Gastroenterology, Fujian Provincial Hospital, Fujian Medical University Provincial of Clinical Medicine, Fuzhou 350001, Fujian Province, China
| | - Yi Zeng
- Department of Gastrointestinal Surgical Oncology, Fujian Cancer Hospital, Fujian Medical University Cancer Hospital, Fuzhou 350014, Fujian Province, China
| | - Zheng-Chao Zhang
- Department of Emergency Surgery, Fujian Provincial Hospital, Fujian Medical University Provincial of Clinical Medicine, Fuzhou 350001, Fujian Province, China
| | - Zhi-Hui Lin
- Department of Gastroenterology, Fujian Provincial Hospital, Fujian Medical University Provincial of Clinical Medicine, Fuzhou 350001, Fujian Province, China
| | - Lu-Chuan Chen
- Department of Gastrointestinal Surgical Oncology, Fujian Cancer Hospital, Fujian Medical University Cancer Hospital, Fuzhou 350014, Fujian Province, China
| | - Zai-Sheng Ye
- Department of Gastrointestinal Surgical Oncology, Fujian Cancer Hospital, Fujian Medical University Cancer Hospital, Fuzhou 350014, Fujian Province, China
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19
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Barclay K, Koysombat K, Padmagirison R, Kaplan F. Hypertriglyceridaemia in pregnancy: an unexpected diagnosis and its management. BMJ Case Rep 2022; 15:15/8/e249000. [PMID: 36038155 PMCID: PMC9438015 DOI: 10.1136/bcr-2022-249000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
A woman in her 30s with gestational diabetes presented at 36 weeks’ gestation with reduced fetal movements and diminishing insulin requirements. In view of her gestation, she was induced and incidentally found to have profound hyponatraemia. Further biochemical investigations confirmed severe hypertriglyceridaemia and hypercholesterolaemia. This raises the possibility of secondary causes such as familial dysbetalipoproteinemia and polygenetic hypertriglyceridaemia. She was successfully managed by aggressive dietary modification. This involved a supervised fast followed by a fat-free diet. A fenofibrate was proposed but declined due to our patient’s wish to breastfeed. Management required considerable input from the multidisciplinary team. Treatment options to consider are aggressive dietary restriction of fat or the addition of a cholesterol-lowering medication, such as a fibrate. In refractory cases, a supervised fast may be required or, in cases where complications have arisen, apheresis. The patient and her baby made a good recovery with no long-lasting health implications.
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Affiliation(s)
- Kathryn Barclay
- Department of Endocrinology and Diabetes Mellitus, Lister Hospital, Stevenage, UK
| | - Kanyada Koysombat
- Department of Endocrinology and Diabetes Mellitus, Lister Hospital, Stevenage, UK
| | | | - Felicity Kaplan
- Department of Endocrinology and Diabetes Mellitus, Lister Hospital, Stevenage, UK
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20
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Gupta M, Liti B, Barrett C, Thompson PD, Fernandez AB. Prevention and Management of Hypertriglyceridemia-Induced Acute Pancreatitis During Pregnancy: A Systematic Review. Am J Med 2022; 135:709-714. [PMID: 35081380 DOI: 10.1016/j.amjmed.2021.12.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 12/13/2021] [Accepted: 12/15/2021] [Indexed: 11/30/2022]
Abstract
Severe gestational hypertriglyceridemia can lead to acute pancreatitis, with maternal mortality rate of approximately 20%. The recent National Lipid Association part 2 expert panel recommendations provide guidance on monitoring pregnant women at high risk for hyperlipidemia. We suggest that high-risk women have triglyceride levels checked once every trimester. Fasting triglycerides >250 mg/dL should prompt monthly triglyceride levels, screening for gestational diabetes, and implementing a strict low-carbohydrate, low-fat diet, exercise. Fasting triglycerides >500 mg/dL, despite a strict dietary and lifestyle modifications, should prompt treatment with omega-3-fatty acids and continue a fat-restricted diet (<20 g total fat/d or <15% total calories) under the guidance of a registered dietician. The use of fibrates should be considered as a second-line therapy due to their unclear risk versus benefit and potential teratogenic effects. Plasmapheresis should be considered early in asymptomatic pregnant women with fasting triglyceride levels >1000 mg/dL or in pregnant women with clinical signs and symptoms of pancreatitis and triglyceride levels >500 mg/dL despite maximal lifestyle changes and pharmacologic therapy.
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Affiliation(s)
- Manasvi Gupta
- Department of Medicine, University of Connecticut, Farmington
| | - Besiana Liti
- Department of Medicine, University of Connecticut, Farmington; The Heart and Vascular Institute, Hartford Hospital, Hartford, Connecticut
| | | | - Paul D Thompson
- Department of Medicine, University of Connecticut, Farmington; The Heart and Vascular Institute, Hartford Hospital, Hartford, Connecticut
| | - Antonio B Fernandez
- Department of Medicine, University of Connecticut, Farmington; The Heart and Vascular Institute, Hartford Hospital, Hartford, Connecticut.
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21
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Abstract
Hypertriglyceridemia is a common lipid disorder encountered in clinical practice. Plasma triglycerides are a marker for the concentration of triglycerides carried in chylomicrons and very low-density lipoprotein particles. A fasting triglyceride level <150 mg/dL is accepted widely as the upper limit of normal range. Guidelines for hypertriglyceridemia are variable without a global consensus on classification and goals for triglyceride levels. A general classification of hypertriglyceridemia is mild < 200 mg/dL, moderate = 200 to 500 mg/dL, moderate to severe = 500 to 1000 mg/dL, and severe > 1000 mg/dL. Because moderate hypertriglyceridemia does increase atherosclerotic cardiovascular disease risk, it is important to determine the underlying etiology to guide appropriate and timely management. This article provides stepwise recommendations on the diagnosis and management of moderate hypertriglyceridemia, based on 3 common scenarios encountered in clinical practice. Initial steps in management include evaluating for secondary contributors, especially diabetes mellitus. Based on patient characteristics, appropriate management decisions include lifestyle adjustments aimed at weight loss and decreasing alcohol consumption and use of statin and nonstatin therapies.
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Affiliation(s)
- Savitha Subramanian
- Division of Metabolism, Endocrinology and Nutrition, University of Washington, Seattle WA, USA
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22
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Pang J, Li SCH, Chan DC, Sullivan DR, Woodward AM, Watts GF. Hypertriglyceridemia: rationale, design and implementation of the Australian Hypertriglyceridemia Registry. Curr Opin Endocrinol Diabetes Obes 2022; 29:131-140. [PMID: 35066540 DOI: 10.1097/med.0000000000000715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Hypertriglyceridemia (HTG) is a risk factor for atherosclerotic cardiovascular disease (ASCVD), aortic stenosis, hepatic steatosis and pancreatitis. We briefly review the aetiology and treatment of HTG and familial chylomicronemia syndrome (FCS), as well as the implementation of a clinical quality registry for improving care, the Australian Hypertriglyceridemia (AUSTRIG) Registry. RECENT FINDINGS There is a need to improve the detection of individuals with severe HTG and FCS, who could benefit from more intense and novel treatments to prevent end-organ damage. Patient registries provide valuable data for advancing care of individuals with severe HTG at high risk of acute pancreatitis, steatohepatitis and ASCVD. However, there is a paucity of registries of such patients. We outline the design and implementation of the AUSTRIG Registry. SUMMARY Clinical registries can be employed in many ways for improving outcomes for patients with HTG, through the collation and analysis of data for enabling health service planning, clinical trials and audits, and for better informing and empowering registrants.
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Affiliation(s)
- Jing Pang
- Medical School, Faculty of Health and Medical Sciences, University of Western Australia, Perth
| | - Stephen C H Li
- Core Pathology & Clinical Chemistry, Pathology West, Westmead Hospital, NSW Health Pathology, Westmead
| | - Dick C Chan
- Medical School, Faculty of Health and Medical Sciences, University of Western Australia, Perth
| | - David R Sullivan
- Department of Chemical Pathology, Royal Prince Alfred Hospital, NSW Health Pathology, Camperdown
| | - Ann-Marie Woodward
- Lipid Disorders Clinic, Departments of Cardiology and Internal Medicine, Royal Perth Hospital, Perth, Australia
| | - Gerald F Watts
- Medical School, Faculty of Health and Medical Sciences, University of Western Australia, Perth
- Lipid Disorders Clinic, Departments of Cardiology and Internal Medicine, Royal Perth Hospital, Perth, Australia
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23
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Abstract
Hypertriglyceridemia (HTG) is among the most common dyslipidemias seen in clinical practice. Studies in recent years have demonstrated a causal relationship between triglyceride-rich lipoproteins (TRL) and cardiovascular disease (CVD). This is primarily due to enhanced atherogenicity of cholesterol-enriched remnants, the metabolic byproducts of TRLs. Other factors influencing atherogenicity of TRLs include apolipoprotein CIII-directed proinflammatory signaling pathways and triglyceride enrichment of low-density lipoprotein that results in overabundance of small dense atherogenic particles within a prooxidative milieu that serves as the gateway for unregulated incorporation by vascular wall macrophages. HTG is caused by familial and metabolic disorders as well as selected medications that impair TRL hydrolysis.
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Affiliation(s)
- Najdat Bazarbashi
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Michael Miller
- Department of Cardiovascular Medicine, University of Maryland School of Medicine, 110 South Paca Street, Baltimore, MD, USA.
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24
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Lewis GF, Hegele RA. Effective, disease-modifying, clinical approaches to patients with mild-to-moderate hypertriglyceridaemia. Lancet Diabetes Endocrinol 2022; 10:142-148. [PMID: 34922644 DOI: 10.1016/s2213-8587(21)00284-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 10/01/2021] [Accepted: 10/03/2021] [Indexed: 02/07/2023]
Abstract
Plasma triglyceride concentration is easily, inexpensively, and accurately measured, and when elevated is a highly informative disease marker that identifies individuals who frequently have a host of underlying metabolic, inflammatory, and atherogenic risk factors. Although this concept aligns with much that has been discussed regarding the metabolic syndrome, individuals identified with mild-to-moderate hypertriglyceridaemia on a screening lipid profile are not necessarily recognised as having features of the metabolic syndrome and frequently do not receive definitive, meaningful, disease-modifying therapy. This treatment would include (1) lifestyle modification; (2) LDL-lowering therapies to aggressively treat elevated apolipoprotein B-containing particles; (3) antihypertensive therapies that have optimal therapeutic profiles for those individuals with metabolic syndrome; (4) icosapent ethyl for those individuals at high risk, particularly patients with established atherosclerotic cardiovascular disease who have residual hypertriglyceridaemia despite treatment with appropriate LDL-lowering therapies; (5) preferential use of cardiovascular protective diabetes therapies, in individuals with diabetes; and (6) antithrombotic therapies for secondary prevention of atherosclerotic cardiovascular disease in the context of high vascular disease risk and diabetes. Several emerging therapies, such as novel weight reducing, anti-inflammatory, lipid-modifying therapies, and therapies targeting the progression of non-alcoholic fatty liver disease, could also soon enter the clinical arena for patients with mild-to-moderate hypertriglyceridaemia and associated metabolic syndrome.
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Affiliation(s)
- Gary F Lewis
- Department of Medicine and Department of Physiology, Division of Endocrinology and Metabolism, Banting and Best Diabetes Centre, University of Toronto, Toronto, ON, Canada; Department of Medicine, Toronto General Hospital, Toronto, ON, Canada.
| | - Robert A Hegele
- Department of Medicine, Department of Biochemistry, and The Robarts Research Institute, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
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25
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Rader DJ, Maratos-Flier E, Nguyen A, Hom D, Ferriere M, Li Y, Kompa J, Martic M, Hinder M, Basson CT, Yowe D, Diener J, Goldfine AB. LLF580, an FGF21 Analog, Reduces Triglycerides and Hepatic Fat in Obese Adults With Modest Hypertriglyceridemia. J Clin Endocrinol Metab 2022; 107:e57-e70. [PMID: 34431493 PMCID: PMC8914500 DOI: 10.1210/clinem/dgab624] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Indexed: 11/19/2022]
Abstract
PURPOSE To evaluate the safety and potential efficacy of LLF580, a genetically engineered variant of human fibroblast growth factor-21, for triglyceride lowering, weight loss, and hepatic fat reduction. METHODS A multicenter, double-blind, parallel design trial in obese, mildly hypertriglyceridemic adults randomized (1:1) to LLF580 300 mg or placebo subcutaneously every 4 weeks for 3 doses. RESULTS Of 64 randomized study participants, 61 (mean ± SD: age 45 ± 11 years, 49% male, 80/15/5% Caucasian/African American/other, body mass index 36.1 ± 3.8 kg/m2) received LLF580 (n = 30) or placebo (n = 31) at 7 research sites in the United States. LLF580 lowered serum triglycerides by 54% (least square mean placebo adjusted change from baseline), total cholesterol 7%, low-density lipoprotein cholesterol 12%, and increased high-density lipoprotein cholesterol 36% compared with placebo (all P < 0.001) over 12 weeks. Substantial reduction of liver fat of 52% over placebo (P < 0.001) was also demonstrated in the setting of improved liver function tests including alanine aminotransferase, aspartate aminotransferase, and alkaline phosphatase, the composite enhanced liver fibrosis score, and N-terminal type III collagen propeptide (all P < 0.05). Insulin and C-peptide levels and insulin resistance by homeostatic model assessment for insulin resistance were all lower, and adiponectin higher with LLF580 treatment compared with placebo, whereas fasting glucose and glycated hemoglobin were unchanged. Reductions in biomarkers of bone formation without differences in markers of bone resorption were observed. LLF580 was generally safe and well tolerated, except for higher incidence of generally mild to moderate gastrointestinal adverse effects. CONCLUSIONS In obese, mildly hypertriglyceridemic adults, LLF580 was generally safe and demonstrated beneficial effects on serum lipids, liver fat, and biomarkers of liver injury, suggesting it may be effective for treatment of select metabolic disorders including hypertriglyceridemia and nonalcoholic fatty liver disease. Assessments of longer term safety and efficacy are warranted. CLINICALTRIALS.GOV IDENTIFIER NCT03466203.
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Affiliation(s)
- Daniel J Rader
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | | | - Amanda Nguyen
- Novartis Institutes for BioMedical Research, Cambridge, MA, USA and Basel, Switzerland
| | - Doug Hom
- Novartis Institutes for BioMedical Research, Cambridge, MA, USA and Basel, Switzerland
| | - Michael Ferriere
- Novartis Institutes for BioMedical Research, Cambridge, MA, USA and Basel, Switzerland
| | - Yifang Li
- Novartis Institutes for BioMedical Research, Cambridge, MA, USA and Basel, Switzerland
| | - Jill Kompa
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | | | - Markus Hinder
- Novartis Institutes for BioMedical Research, Cambridge, MA, USA and Basel, Switzerland
| | - Craig T Basson
- Novartis Institutes for BioMedical Research, Cambridge, MA, USA and Basel, Switzerland
| | - David Yowe
- Novartis Institutes for BioMedical Research, Cambridge, MA, USA and Basel, Switzerland
| | - John Diener
- Novartis Institutes for BioMedical Research, Cambridge, MA, USA and Basel, Switzerland
| | - Allison B Goldfine
- Correspondence: Allison B. Goldfine, MD, Novartis Institute of Biomedical Research, 220 Massachusetts Ave, Cambridge, MA, 02139, USA.
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Zhang M, Yin T, Xia F, Xia S, Zhou W, Zhang Y, Han X, Zhao K, Feng L, Dong R, Tian D, Yu Y, Liao J. Hypertriglyceridemia may contribute to stroke and pancreatitis: A case report and review of the literature. Front Endocrinol (Lausanne) 2022; 13:960343. [PMID: 36531479 PMCID: PMC9751361 DOI: 10.3389/fendo.2022.960343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 11/17/2022] [Indexed: 12/03/2022] Open
Abstract
Hypertriglyceridemia (HTG) is one of the most common clinical dyslipidemia. Nevertheless, stroke and acute pancreatitis co-occurrence due to hypertriglyceridemia are extremely rare. We present a case of hypertriglyceridemia-associated stroke and pancreatitis in a 39-year-old woman. The patient's laboratory tests reported high triglyceride concentrations beyond the instrument's detection range, and radiological examination showed typical signs of cerebral infarction and acute pancreatitis. The patient received combined blood purification therapy, intravenous thrombolysis with urokinase, and conservative treatment of pancreatitis. We discuss the clinical features, pathogenesis, diagnosis, and treatment of hypertriglyceridemic stroke and pancreatitis combined with the relevant literature. We reviewed the mechanisms by which triglycerides contribute to atherosclerosis and acute pancreatitis. We point out the superiority of combined blood purification therapy and caution physicians about the effects of prescribed drugs on blood lipids.
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Affiliation(s)
- Mingyu Zhang
- Department of Gastroenterology, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Taoyuan Yin
- Department of Biliary-Pancreatic Surgery, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Feng Xia
- Department of Hepatic Surgery Center, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Suhong Xia
- Department of Gastroenterology, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Wangdong Zhou
- Department of Gastroenterology, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Yu Zhang
- Department of Gastroenterology, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Xu Han
- Department of Gastroenterology, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Kai Zhao
- Department of Gastroenterology, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Lina Feng
- Department of Gastroenterology, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Ruonan Dong
- Department of Gastroenterology, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Dean Tian
- Department of Gastroenterology, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Yan Yu
- Department of Gastroenterology, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
- *Correspondence: Yan Yu, ; Jiazhi Liao,
| | - Jiazhi Liao
- Department of Gastroenterology, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
- *Correspondence: Yan Yu, ; Jiazhi Liao,
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Gallo A, Bruckert É. [Management of hypertriglyceridemia]. Rev Prat 2021; 71:792. [PMID: 34792920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Affiliation(s)
- Antonio Gallo
- Unité de prévention des maladies cardiovasculaires, pôle cardiologie/ métabolisme, hôpital La Pitié-Salpêtrière, AP-HP, 75013 Paris, France
| | - Éric Bruckert
- Unité de prévention des maladies cardiovasculaires, pôle cardiologie/ métabolisme, hôpital La Pitié-Salpêtrière, AP-HP, 75013 Paris, France
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Virani SS, Morris PB, Agarwala A, Ballantyne CM, Birtcher KK, Kris-Etherton PM, Ladden-Stirling AB, Miller M, Orringer CE, Stone NJ. 2021 ACC Expert Consensus Decision Pathway on the Management of ASCVD Risk Reduction in Patients With Persistent Hypertriglyceridemia: A Report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol 2021; 78:960-993. [PMID: 34332805 DOI: 10.1016/j.jacc.2021.06.011] [Citation(s) in RCA: 124] [Impact Index Per Article: 41.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Dimache AM, Șalaru DL, Sascău R, Stătescu C. The Role of High Triglycerides Level in Predicting Cognitive Impairment: A Review of Current Evidence. Nutrients 2021; 13:2118. [PMID: 34203094 PMCID: PMC8234148 DOI: 10.3390/nu13062118] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 06/13/2021] [Accepted: 06/18/2021] [Indexed: 12/13/2022] Open
Abstract
The burden of cognitive disorders is huge and still growing, however the etiology and the degree of cognitive impairment vary considerably. Neurodegenerative and vascular mechanisms were most frequently assessed in patients with dementia. Recent studies have shown the possible involvement of triglycerides levels in cognitive function through putative mechanisms such as brain blood barrier dysfunction or amyloid metabolism imbalance, but not all research in the field found this association. Several clinical studies evaluated the relationship between different forms of cognitive decline and levels of serum triglycerides, independent of other cardiovascular risk factors. This review focuses on the role of triglycerides in cognitive decline, cerebral amyloidosis and vascular impairment. Considering that the management of hypertriglyceridemia benefits from lifestyle modification, diet, and specific drug therapy, future studies are requested to appraise the triglycerides-cognitive impairment relationship.
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Affiliation(s)
- Alina Mihaela Dimache
- Neurology Outpatient Clinic, Department of Chronic Diseases, Hospital of Chronic Diseases Târgu Frumos, 705300 Iași, Romania;
| | - Delia Lidia Șalaru
- Faculty of Medicine, University of Medicine and Pharmacy Grigore T. Popa, 700115 Iași, Romania; (R.S.); (C.S.)
- Institute of Cardiovascular Diseases, 700503 Iasi, Romania
| | - Radu Sascău
- Faculty of Medicine, University of Medicine and Pharmacy Grigore T. Popa, 700115 Iași, Romania; (R.S.); (C.S.)
- Institute of Cardiovascular Diseases, 700503 Iasi, Romania
| | - Cristian Stătescu
- Faculty of Medicine, University of Medicine and Pharmacy Grigore T. Popa, 700115 Iași, Romania; (R.S.); (C.S.)
- Institute of Cardiovascular Diseases, 700503 Iasi, Romania
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Tang S, Liu Y, Liu C, Zhao J. Effect of plasmapheresis versus standard treatment in preventing recurrent acute pancreatitis in Chinese patients with hypertriglyceridemia. Pak J Pharm Sci 2021; 34:1255-1259. [PMID: 34602397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
The present study designed to compare the effect of plasmapheresis (PPH) versus standard treatment (STD) in preventing recurrent AP in Chinese patients with severe hypertriglyceridemia. Chinese patients aged 18 to 65 years who had history of hypertriglyceridemia (>1000mg/dl) induced acute pancreatitis were assigned to plasmapheresis (up to 1.5 ml daily TG level reaches 500 mg/dl or less) or standard treatment (1:1). Standard treatment (STD) includes limited oral intake (pancreatic rest), intravenous hydration and pain management. Primary endpoint was incidence of recurrent acute pancreatitis. A total of 14% of patients in PPH group (N=50) had experienced recurrent pancreatitis as compared to 24% of patients in STD group (N=50). Also, TG clearance rate in 24 hours was substantially higher in PPH group as compared to STD. Time required to reach target TG was significantly lower in patients treated with PPH as compared to STD. Lower incidence of local complications was observed in PPH group as compared to STD. Length of stay was significantly shorter in patients of plasmapheresis group as compared to standard treatment. The results of this study recommend the use of plasmapheresis as a better alternative in preventing recurrent AP in Chinese patients with severe hypertriglyceridemia.
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Affiliation(s)
- Shunyu Tang
- Department of Gastroenterology, Jingmen First People's Hospital, Jingmen, Hubei, China
| | - Yun Liu
- Department of Endoscopic Center, Jingmen First People's Hospital, Jingmen, Hubei, China
| | - Changqing Liu
- Department of Gastroenterology, Jingmen First People's Hospital, Jingmen, Hubei, China
| | - Jiayun Zhao
- Department of Hepatobiliary and Pancreatic Surgery, Jingmen First People's Hospital, Jingmen, Hubei, China
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Huang Z, Xu Z, Xu R, Huang L, Xu X, Lai X. Whole exome sequencing identifies three novel gene mutations in patients with the triad of diabetic ketoacidosis, hypertriglyceridemia, and acute pancreatitis. J Diabetes 2021; 13:200-210. [PMID: 32734598 DOI: 10.1111/1753-0407.13100] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 07/05/2020] [Accepted: 07/24/2020] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND This study aimed to analyze the genetics and treatments of the patients with the triad of diabetic ketoacidosis (DKA), hypertriglyceridemia, and acute pancreatitis (AP). METHODS We conducted a retrospective study of six patients with the triad of AP, hypertriglyceridemia, and DKA at our hospital. All patients underwent plasmapheresis as part of their treatment. The clinical characteristics of the patients were obtained from the hospital information system and analyzed. Whole exome sequencing was performed using samples of one patient (case 6) and his family members. RESULTS The average triglyceride level before plasmapheresis was 3282.17 ± 2975.43 mg/dL (range: 1646-9332 mg/dL). The triglyceride levels dropped by approximately 80% after plasmapheresis. None of the patients developed complications related from plasmapheresis. During follow-up, patients 5 and 6 developed recurrent pancreatitis for several times and showed the formation of pancreatic pseudocysts. We identified three novel heterozygous missense mutations in the family of patient 6, including c.12614C > T (p.Pro4205Leu) in APOB, c.160G > C (p.Glu54Gln) in CILP2, and c.1199C > A (p.Ala400Glu) in PEPD. CONCLUSIONS Three novel heterozygous missense mutations, including c.12614C > T (p.Pro4205Leu) in APOB, c.160G > C (p.Glu54Gln) in CILP2, and c.1199C > A (p.Ala400Glu) in PEPD were first identified in a patient with the triad of DKA, hypertriglyceridemia, and AP. The combination of plasmapheresis, hydration, and insulin therapy may have the greatest clinical benefits for these patients.
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Affiliation(s)
- Zixi Huang
- Department of General Medicine, The Second Affiliated Hospital of Nanchang University, Nanchang, China
- Department of Endocrinology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Zhenyan Xu
- Department of Cardiovascular Medicine, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Ruoqing Xu
- Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Lin Huang
- Department of Cardiovascular Medicine, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Xiang Xu
- Department of Ultrasound Medicine, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Xiaoyang Lai
- Department of Endocrinology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
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Abstract
BACKGROUND AND AIMS Dyslipidemia is a common problem in diabetic patients that predisposes to premature ASCVD. Dyslipidemia in Type 2 diabetes (T2DM) is very common and is characterized by hypertriglyceridemia (HTG) with decreased levels of high-density lipoprotein (HDL)-cholesterol. METHODS Recommendations for lipid testing in diabetics from the Canadian, European and American guidelines will be discussed in this mini-review. RESULTS It is crucial to obtain appropriate lipid testing in patients with TG > 2.3 mmol/L and or LDL-C< 1.8 mmol/L. We also discuss the utility of the different measures of calculated LDL-C and their pitfalls. CONCLUSION In conclusion, we propose obtaining a non-HDL-C (preferred) or direct -LDL-C or apo B level to manage diabetic patients with dyslipidemia and optimize care. Also in some patients with a strong FH of premature ASCVD and have few or no risk factors, Lp (a) can be assayed to optimize statin therapy.
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Affiliation(s)
- Sridevi Devaraj
- Department of Pathology and Immunology, Baylor College of Medicine, Houston, TX, USA.
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Abstract
PURPOSE OF REVIEW Hypertriglyceridemia (HTG), a form of dyslipidemia characterized by elevated plasma of triglycerides (TG), is associated with an increased risk for acute pancreatitis. Moreover, HTG has recently been shown to be linked to the development of atherosclerotic cardiovascular disease (ASCVD); therefore, there is a great interest in better understanding the pathophysiology of HTG and improving its clinical management. In this review, we briefly describe TG metabolism, recent guidelines for the clinical management of HTG and provide an overview of the current and potential new therapies for HTG. RECENT FINDINGS Screening patients for HTG is valuable for not only identifying patients with extreme TG elevations, who are at risk for pancreatitis, but also for managing ASCVD risk in patients with more moderate forms of HTG. Therefore, the most recent USA guidelines for cardiovascular diseases recommend using TG as a risk enhancer test, leading to a more aggressive treatment of patients with intermediate risk. Currently, there are several available approaches for reducing plasma TG, which include lifestyle changes, fibrates and omega-3 fatty acid treatment. The addition of eicosapentaenoic acid (EPA) on top of statins has recently been shown to significantly reduce ASCVD events. Nevertheless, there is an unmet need for more effective treatment options. Several new therapies based on newly identified targets in TG metabolism, such as apolipoprotein C-III and angiopoietin-like 3 protein, are currently under development. SUMMARY The clinical management of HTG is important in the prevention and treatment of acute pancreatitis and also impacts on how ASCVD risk is managed. More work needs to be done to establish the mechanism for the ability of how EPA lowers ASCVD and how to best integrate it with other lipid-lowering therapies. The efficacy and safety of the novel therapies for HTG should be established soon in the ongoing late-stage clinical trials.
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Affiliation(s)
- Anna Wolska
- Corresponding author: Anna Wolska, Lipoprotein Metabolism Laboratory, Translational Vascular Medicine Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, 9000 Rockville Pike Build.10/Rm.5D15, Bethesda, MD, 20892, USA,
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Abstract
Hypertriglyceridemia is one of the most common lipid abnormalities encountered in clinical practice. Many monogenic disorders causing severe hypertriglyceridemia have been identified, but in most patients triglyceride elevations result from a combination of multiple genetic variations with small effects and environmental factors. Common secondary causes include obesity, uncontrolled diabetes, alcohol misuse, and various commonly used drugs. Correcting these factors and optimizing lifestyle choices, including dietary modification, is important before starting drug treatment. The goal of drug treatment is to reduce the risk of pancreatitis in patients with severe hypertriglyceridemia and cardiovascular disease in those with moderate hypertriglyceridemia. This review discusses the various genetic and acquired causes of hypertriglyceridemia, as well as current management strategies. Evidence supporting the different drug and non-drug approaches to treating hypertriglyceridemia is examined, and an easy to adopt step-by-step management strategy is presented.
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Affiliation(s)
- Vinaya Simha
- Division of Endocrinology, Mayo Clinic, Rochester, MN 55905, USA
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Acar YA, Gunay G, Bilge S, Tezel O. Concomitant hypertriglyceridemia-induced pancreatitis in pregnant monozygotic twin siblings. Gynecol Endocrinol 2020; 36:654-656. [PMID: 32157928 DOI: 10.1080/09513590.2020.1737669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
Hypertriglyceridemia-induced pancreatitis (HTIP) is the third most common cause of pancreatitis. Hypertriglyceridemia shows familial transition and pregnancy increases the risk of HTIP. The treatment of HTIP is initiated with supportive treatment and continues with specific treatments including plasmapheresis, insulin, heparin infusion, and hemofiltration. The current study reports monozygotic twins who are pregnant at the same time having concurrent HTIP attack.
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Affiliation(s)
- Yahya Ayhan Acar
- Department of Emergency Medicine, University of Health Sciences, Ankara, Turkey
| | - Gizem Gunay
- Department of Emergency Medicine, University of Health Sciences, Ankara, Turkey
| | - Sedat Bilge
- Department of Emergency Medicine, University of Health Sciences, Ankara, Turkey
| | - Onur Tezel
- Department of Emergency Medicine, University of Health Sciences, Ankara, Turkey
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Zádori N, Gede N, Antal J, Szentesi A, Alizadeh H, Vincze Á, Izbéki F, Papp M, Czakó L, Varga M, de-Madaria E, Petersen OH, Singh VP, Mayerle J, Faluhelyi N, Miseta A, Reiber I, Hegyi P. EarLy Elimination of Fatty Acids iN hypertriglyceridemia-induced acuTe pancreatitis (ELEFANT trial): Protocol of an open-label, multicenter, adaptive randomized clinical trial. Pancreatology 2020; 20:369-376. [PMID: 31959416 DOI: 10.1016/j.pan.2019.12.018] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Revised: 12/03/2019] [Accepted: 12/20/2019] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Acute pancreatitis (AP) is a life-threatening inflammatory disease, with no specific pharmacological treatment. However, concerning some etiologies, early specific intervention (such as ERCP in biliary AP) has proven to be remarkably beneficial. Hypertriglyceridemia (HTG) induces severe pancreatic damage by several direct (cellular damage) and indirect (deterioration of microcirculation) mechanisms. Published data suggest that early removal of triglycerides (TGs) and toxic free fatty acids (FFAs) may be advantageous; however, high-quality evidence is still missing in the literature. METHODS Design: ELEFANT is a randomized controlled, multicenter, international trial testing the concept that early elimination of TGs and FFAs from the blood is beneficial in HTG-AP. The study will be performed with the adaptive "drop-the-loser" design, which supports the possibility of dropping the inferior treatment arm, based on the results of the interim analysis. Patients with HTG-AP defined by TG level over 11.3 mmol/l (1000 mg/dL) are randomized into three groups: (A) patients who undergo plasmapheresis and receive aggressive fluid resuscitation; (B) patients who receive insulin and heparin treatment with aggressive fluid resuscitation; and (C) patients with aggressive fluid resuscitation. Please note that all intervention must be started within 48 h from the onset of abdominal pain. Exclusion criteria are designed logically to decrease the possibility of any distorting effects of other diseases. The composite primary endpoint will include both severity and mortality. RESULTS Our null hypothesis is that early elimination of HTG and FFAs reduces the risk of mortality and severity of AP. Sample size calculation suggests that 495 patients will need to be enrolled in order to confirm or reject the hypothesis with a 10% dropout, 80% power and 95% significance level. The general safety and quality checks required for high-quality evidence will be adhered to. The study will be organized between February 2020 and December 2025. CONCLUSION Our study would provide the first direct evidence for or against early intervention in HTG-induced AP.
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Affiliation(s)
- Noémi Zádori
- Institute for Translational Medicine, Szentágothai Research Centre, Medical School, University of Pécs, Pécs, Hungary. http://www.tm-centre.org
| | - Noémi Gede
- Institute for Translational Medicine, Szentágothai Research Centre, Medical School, University of Pécs, Pécs, Hungary.
| | - Judit Antal
- Institute for Translational Medicine, Szentágothai Research Centre, Medical School, University of Pécs, Pécs, Hungary.
| | - Andrea Szentesi
- Institute for Translational Medicine, Szentágothai Research Centre, Medical School, University of Pécs, Pécs, Hungary; Hungarian Academy of Sciences-University of Szeged, Translational Multidisciplinary Research Group, Szeged, Hungary.
| | - Hussain Alizadeh
- Division of Hematology, First Department of Internal Medicine, University of Pécs Medical School, Pécs, Hungary.
| | - Áron Vincze
- Institute for Translational Medicine, Szentágothai Research Centre, Medical School, University of Pécs, Pécs, Hungary; Division of Gastroenterology, First Department of Internal Medicine, University of Pécs Medical School, Pécs, Hungary.
| | - Ferenc Izbéki
- Division of Gastroenterology, Fejér County Saint George Teaching Hospital of the University of Pécs, Székesfehérvár, Hungary.
| | - Mária Papp
- Department of Internal Medicine, Division of Gastroenterology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary.
| | - László Czakó
- First Department of Internal Medicine, University of Szeged, Szeged, Hungary.
| | - Márta Varga
- Dr. Réthy Pál Hospital, Békéscsaba, Hungary.
| | - Enrique de-Madaria
- Department of Gastroenterology, Alicante University General Hospital, Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain.
| | | | - Vijay P Singh
- Department of Medicine, Mayo Clinic, Scottsdale, AZ, USA.
| | - Julia Mayerle
- Medizinische Klinik und Poliklinik II, Klinikum der Universität München, München, Germany.
| | | | - Attila Miseta
- Department of Laboratory Medicine, University of Pécs, Pécs, Hungary.
| | - István Reiber
- Division of Gastroenterology, Fejér County Saint George Teaching Hospital of the University of Pécs, Székesfehérvár, Hungary.
| | - Péter Hegyi
- Institute for Translational Medicine, Szentágothai Research Centre, Medical School, University of Pécs, Pécs, Hungary; Hungarian Academy of Sciences-University of Szeged, Translational Multidisciplinary Research Group, Szeged, Hungary. http://www.tm-centre.org
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Garelli V, Pauchet A, Kissling S, Sartori C, Rodondi N, Collet TH. [The management of hypertriglyceridemia and the risk of pancreatitis]. Rev Med Suisse 2020; 16:451-454. [PMID: 32134224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
In the face of hypertriglyceridemia, the potential causes must be assessed to choose the best medical therapeutic option. In cases of secondary hypertriglyceridemia, physicians should use treatments targeting the pathophysiological mechanisms underlying the lipid disorder. Lifestyle interventions are the cornerstone of an effective treatment, to achieve controlled glycemia, blood pressure and weight loss. Only in cases where these measures are insufficient, fibrates can be trialed although their clinical benefit is controversial, with special caution when combined with statins (risk of rhabdomyolysis). Plasmapheresis or intravenous insulin therapy are only used in severe situations after a multidisciplinary decision process in the hospital setting. The clinical case presented here reminds us to assess hypertriglyceridemia in the face of any acute pancreatitis.
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Affiliation(s)
- Valentina Garelli
- Service de médecine interne, CHUV et Université de Lausanne, 1011 Lausanne
| | - Amélie Pauchet
- Consultation spécialisée des lipides, Service d'endocrinologie, diabétologie et métabolisme, CHUV et Université de Lausanne, 1011 Lausanne
| | - Sébastien Kissling
- Service de néphrologie, Département de médecine, CHUV et Université de Lausanne, 1011 Lausanne
| | - Claudio Sartori
- Service de médecine interne, CHUV et Université de Lausanne, 1011 Lausanne
| | - Nicolas Rodondi
- Consultation des lipides, Policlinique médicale, Clinique universitaire de médecine interne générale, Hôpital de l'Ile, 3010 Berne
- Berner Institut für Hausarztmedizin (BIHAM), Université de Berne, 3010 Berne
| | - Tinh-Hai Collet
- Consultation spécialisée des lipides, Service d'endocrinologie, diabétologie et métabolisme, CHUV et Université de Lausanne, 1011 Lausanne
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Skulas-Ray AC, Wilson PWF, Harris WS, Brinton EA, Kris-Etherton PM, Richter CK, Jacobson TA, Engler MB, Miller M, Robinson JG, Blum CB, Rodriguez-Leyva D, de Ferranti SD, Welty FK. Omega-3 Fatty Acids for the Management of Hypertriglyceridemia: A Science Advisory From the American Heart Association. Circulation 2019; 140:e673-e691. [PMID: 31422671 DOI: 10.1161/cir.0000000000000709] [Citation(s) in RCA: 215] [Impact Index Per Article: 43.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Hypertriglyceridemia (triglycerides 200-499 mg/dL) is relatively common in the United States, whereas more severe triglyceride elevations (very high triglycerides, ≥500 mg/dL) are far less frequently observed. Both are becoming increasingly prevalent in the United States and elsewhere, likely driven in large part by growing rates of obesity and diabetes mellitus. In a 2002 American Heart Association scientific statement, the omega-3 fatty acids (n-3 FAs) eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) were recommended (at a dose of 2-4 g/d) for reducing triglycerides in patients with elevated triglycerides. Since 2002, prescription agents containing EPA+DHA or EPA alone have been approved by the US Food and Drug Administration for treating very high triglycerides; these agents are also widely used for hypertriglyceridemia. The purpose of this advisory is to summarize the lipid and lipoprotein effects resulting from pharmacological doses of n-3 FAs (>3 g/d total EPA+DHA) on the basis of new scientific data and availability of n-3 FA agents. In treatment of very high triglycerides with 4 g/d, EPA+DHA agents reduce triglycerides by ≥30% with concurrent increases in low-density lipoprotein cholesterol, whereas EPA-only did not raise low-density lipoprotein cholesterol in very high triglycerides. When used to treat hypertriglyceridemia, n-3 FAs with EPA+DHA or with EPA-only appear roughly comparable for triglyceride lowering and do not increase low-density lipoprotein cholesterol when used as monotherapy or in combination with a statin. In the largest trials of 4 g/d prescription n-3 FA, non-high-density lipoprotein cholesterol and apolipoprotein B were modestly decreased, indicating reductions in total atherogenic lipoproteins. The use of n-3 FA (4 g/d) for improving atherosclerotic cardiovascular disease risk in patients with hypertriglyceridemia is supported by a 25% reduction in major adverse cardiovascular events in REDUCE-IT (Reduction of Cardiovascular Events With EPA Intervention Trial), a randomized placebo-controlled trial of EPA-only in high-risk patients treated with a statin. The results of a trial of 4 g/d prescription EPA+DHA in hypertriglyceridemia are anticipated in 2020. We conclude that prescription n-3 FAs (EPA+DHA or EPA-only) at a dose of 4 g/d (>3 g/d total EPA+DHA) are an effective and safe option for reducing triglycerides as monotherapy or as an adjunct to other lipid-lowering agents.
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Shabtaie SA, Codipilly DC, Sweetser S. 32-Year-Old Man With New Onset Abdominal Pain. Mayo Clin Proc 2019; 94:1589-1593. [PMID: 31378233 DOI: 10.1016/j.mayocp.2018.11.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 11/15/2018] [Accepted: 11/30/2018] [Indexed: 11/18/2022]
Affiliation(s)
- Samuel A Shabtaie
- Resident in Internal Medicine, Mayo Clinic School of Graduate Medical Education, Rochester, MN
| | - Don Chamil Codipilly
- Resident in Gastroenterology and Hepatology, Mayo Clinic School of Graduate Medical Education, Rochester, MN
| | - Seth Sweetser
- Advisor to residents and Consultant in Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN.
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YILDIRIM ŞİMŞİR I, SOYALTIN UE, SARER YÜREKLİ B, ERDOĞAN M, ÇETİNKALP Ş, SAYGILI F, DÖNMEZ A, ÖZGEN AG. Therapeutic plasma exchange in hypertriglyceridemic patients. Turk J Med Sci 2019; 49:872-878. [PMID: 31203594 PMCID: PMC7018319 DOI: 10.3906/sag-1811-105] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Background/aim High triglyceride (TG) levels are associated with increases in atherosclerotic cardiovascular disease (CVD), hepatic steatosis, and pancreatitis. Acute pancreatitis is a condition with high mortality. Therapeutic plasma exchange (TPE) in the treatment of hypertriglyceridemic pancreatitis (HTGP) is a rapid and effective treatment modality. In this study, the results of TPE were evaluated and the frequency of lipoprotein lipase (LPL) mutation in these patients was determined. Materials and methods TPE was performed in 31 patients with HTGP at the Adult Therapeutic Apheresis Center. Results A TG level under 500 mg/dL was achieved by applying apheresis at a median of 2 times (IQR 2–2, min 1, max 6) in the 31 cases. LPL mutation was detected in 8 (25.8%) of the 31 hypertriglyceridemia cases. When TG levels before and after TPE were evaluated, the mean TG level before TPE was significantly higher (3132 ± 1472 mg/dL) than the mean TG level afterwards (948 ± 465 mg/dL, P < 0.001). This result represented a decrease of 69.7% TG after TPE. Conclusion TPE is a safe, fast, and effective treatment modality in experienced centers.
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Affiliation(s)
- Ilgın YILDIRIM ŞİMŞİR
- Department of Internal Medicine, Division of Endocrinology and Metabolism Disorders, Faculty of Medicine, Ege University, İzmirTurkey
- * To whom correspondence should be addressed. E-mail:
| | - Utku Erdem SOYALTIN
- Department of Internal Medicine, Division of Endocrinology and Metabolism Disorders, Faculty of Medicine, Ege University, İzmirTurkey
| | - Banu SARER YÜREKLİ
- Department of Internal Medicine, Division of Endocrinology and Metabolism Disorders, Faculty of Medicine, Ege University, İzmirTurkey
| | - Mehmet ERDOĞAN
- Department of Internal Medicine, Division of Endocrinology and Metabolism Disorders, Faculty of Medicine, Ege University, İzmirTurkey
| | - Şevki ÇETİNKALP
- Department of Internal Medicine, Division of Endocrinology and Metabolism Disorders, Faculty of Medicine, Ege University, İzmirTurkey
| | - Füsun SAYGILI
- Department of Internal Medicine, Division of Endocrinology and Metabolism Disorders, Faculty of Medicine, Ege University, İzmirTurkey
| | - Ayhan DÖNMEZ
- Department of Internal Medicine, Division of Hematology, Faculty of Medicine, Ege University, İzmirTurkey
| | - Ahmet Gökhan ÖZGEN
- Department of Internal Medicine, Division of Endocrinology and Metabolism Disorders, Faculty of Medicine, Ege University, İzmirTurkey
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Wang Y, Shen L, Xu D. Aerobic exercise reduces triglycerides by targeting apolipoprotein C3 in patients with coronary heart disease. Clin Cardiol 2019; 42:56-61. [PMID: 30511426 PMCID: PMC6436502 DOI: 10.1002/clc.23104] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 10/15/2018] [Accepted: 10/17/2018] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Aerobic exercise, which has been shown to have beneficial effects on plasma lipids, has been recommended as an effective measure to improve the prognosis of individuals with coronary heart disease (CHD). Apolipoprotein C3 (apoC3) is associated with hypertriglyceridemia and is therefore closely related to CHD. HYPOTHESIS We measured apoC3 concentration change in patients with CHD before and after long-term aerobic exercise. METHODS Thirty-eight patients with coronary heart disease were randomly assigned to a non-exercise group (19 patients) or exercise group (19 patients). Both groups received essential drugs for CHD. The non-exercise group was kept sedentary while the exercise group performed moderate-intensive aerobic exercise for 8 weeks. Lipid levels and apoC3 levels were measured on the first day and 8 weeks later. RESULTS Exercise for 8 weeks led to a significant decrease in concentration of triglyceride and apoC3 compared with the baseline. Triglyceride concentration changes were positively associated with apoC3 level changes. CONCLUSIONS Aerobic exercise can improve the lipid profile. It is effective in decreasing triglycerides by targeting apoC3 levels in patients with coronary heart disease.
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Affiliation(s)
- Yating Wang
- Department of Cardiovascular MedicineThe Second Xiangya Hospital, Central South UniversityChangshaChina
| | - Li Shen
- Department of Cardiovascular MedicineThe Second Xiangya Hospital, Central South UniversityChangshaChina
| | - Danyan Xu
- Department of Cardiovascular MedicineThe Second Xiangya Hospital, Central South UniversityChangshaChina
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Huang SP, Toh DE, Sue YM, Chen TH, Cheng SW, Cheng CY. Double filtration plasmapheresis in treatment of acute pancreatitis associated with severe hypertriglyceridemia: Three case reports. Medicine (Baltimore) 2018; 97:e12987. [PMID: 30383651 PMCID: PMC6221692 DOI: 10.1097/md.0000000000012987] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
RATIONALE Severe hypertriglyceridemia is the 3rd-leading cause of acute pancreatitis. Current treatment option for hypertriglyceridemia associated with acute pancreatitis is mainly supportive measures, including adequate fluid supply, pain management, and broad-spectrum antibiotics if necessary. Extracorporeal method by mean of plasmapheresis is effective in reducing serum level of triglyceride. It has been proposed to have therapeutic potential in limited small sample studies. PATIENT CONCERNS A retrospective review of therapeutic effect of double filtration plasmapheresis in treating hypertriglyceridemia associated with acute pancreatitis was conducted by enlisting 3 patients who meet the criteria for the present study. DIAGNOSES Three patients met the criteria for hypertriglyceridemia (serum level >800 mg/dL) associated with acute pancreatitis (either with elevated serum level of lipase and/or amylase and/or with computed tomography evidence of acute pancreatitis). INTERVENTIONS Patients received double filtration plasmapheresis. OUTCOMES We found that an effective reduction of triglyceride was achieved on an average of 84.7% as a result of a single session of plasmapheresis. All 3 of our patients survived, but needed extended hospitalization. LESSONS A substantial clinical trial is required to further assess the effectiveness of plasmapheresis in managing of acute pancreatitis in the setting of hypertriglyceridemia.
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Affiliation(s)
- Shih-Ping Huang
- Division of Gastroenterology, Department of Internal Medicine, Wan Fang Hospital
| | - Ding-Ek Toh
- Division of Gastroenterology, Department of Internal Medicine, Wan Fang Hospital
| | - Yuh-Mou Sue
- Department of Internal Medicine, School of Medicine, College of Medicine
- Division of Nephrology, Department of Internal Medicine, Wan Fang Hospital
| | - Tso-Hsiao Chen
- Department of Internal Medicine, School of Medicine, College of Medicine
- Division of Nephrology, Department of Internal Medicine, Wan Fang Hospital
| | - Sheng-Wei Cheng
- Division of Gastroenterology, Department of Internal Medicine, Wan Fang Hospital
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chung-Yi Cheng
- Department of Internal Medicine, School of Medicine, College of Medicine
- Division of Nephrology, Department of Internal Medicine, Wan Fang Hospital
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Abstract
OBJECTIVE Severe hypertriglyceridemia (HTG) (i.e., plasma triglycerides [TGs] >1,000 mg/dL) in children is a rare but pernicious and understudied condition. Our objective was to evaluate the etiology, characteristics, and sequelae of severe pediatric HTG. METHODS This was a retrospective electronic medical record review of pediatric patients with severe HTG at a tertiary referral Children's hospital over a 17-year period. RESULTS There were a total of 124 patients with severe HTG. The etiology varied: hemato-oncologic (n = 48), diabetes and insulin resistance-related (n = 46), total parenteral nutrition (TPN)-related (n = 6), renal (n = 12), and miscellaneous (n = 12). There was considerable variability in the number of days for the plasma TGs to decrease to <1,000 mg/dL (147.7 ± 567.3 days) and to further decrease to <500 mg/dL (136.84 ± 230.9 days). Patients with diabetes required the longest time to improve their plasma TGs (165.8 ± 305.7 days) compared to other groups. There were 11 cases of pancreatitis, comorbid with diabetes (n = 5), hemato-oncologic conditions (n = 3), and TPN (n = 3). Sixty-seven patients (54%) had persistent HTG. CONCLUSION Severe HTG in pediatrics is commonly due to secondary causes. Patients with diabetes tend to have a longer course of dyslipidemia. A substantial number of patients had persistent dyslipidemia, indicating underlying genetic susceptibility to HTG that is phenotypically expressed consequent to a secondary metabolic insult. ABBREVIATIONS DKA = diabetic ketoacidosis; EMR = electronic medical record; GSD = glycogen storage disorder; HbA1c = hemoglobin A1c; HIV = human immunodeficiency virus; HTG = hypertriglyceridemia; ICD-9 = International Classification of Diseases-Ninth Revision; IV = intravenous; LCHAD = long-chain 3-hydroxyacyl coenzyme A dehydrogenase deficiency; LPL = lipoprotein lipase; NPO = nothing by mouth; PCOS = polycystic ovary syndrome; T1DM = type 1 diabetes mellitus; T2DM = type 2 diabetes mellitus; TG = triglyceride; TPN = total parenteral nutrition; VLDL = very-low-density lipoprotein.
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Mateo-Gallego R, Lacalle L, Pérez-Calahorra S, Marco-Benedí V, Recasens V, Padrón N, Lamiquiz-Moneo I, Baila-Rueda L, Jarauta E, Calmarza P, Cenarro A, Civeira F. Efficacy of repeated phlebotomies in hypertriglyceridemia and iron overload: A prospective, randomized, controlled trial. J Clin Lipidol 2018; 12:1190-1198. [PMID: 30049591 DOI: 10.1016/j.jacl.2018.06.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 06/21/2018] [Accepted: 06/27/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND High ferritin concentration is associated with hypertriglyceridemia, although it is not elucidated if iron overload has a causal role. OBJECTIVE To evaluate the efficacy of repeated phlebotomies in patients with iron overload and hypertriglyceridemia. METHODS Twelve weeks, 1:1 randomized, parallel-groups trial conducted at a University Hospital Lipid Clinic, including 86 subjects aged 18-70 years with serum ferritin >300 ng/mL in men or >200 ng/mL in women and triglycerides >200 mg/dL. Participants underwent: (1) three phlebotomies (every 3 weeks) and lipid-lowering dietary counseling or (2) lipid-lowering dietary counseling. The main outcome measured was the mean difference in percent change in triglyceride concentration between groups after the intervention. The mean differences in percent change of other clinical and biochemical variables (including cytokines and proinflammatory markers) after the intervention were also evaluated. RESULTS Subjects who received phlebotomies showed a significant improvement in iron metabolism. The mean percent change in triglycerides between groups was -4.68 [-20.8, 11.4]%, P = .721. Retinol-binding protein 4 decreased by 9.98 ± 21.7% after phlebotomies, with a mean percent change between groups of -14.2 [-25.8, -2.73]%, P = .017, and correlated to gamma glutamyl transferase, alanine aminotransferase and aspartate aminotransferase change. Subjects with a large reduction in hepcidin showed a large improvement in liver enzymes and proinflammatory markers. CONCLUSIONS A lipid-lowering diet plus a substantial reduction in iron deposits with repeated phlebotomies in subjects with hyperferritinemia and hypertriglyceridemia did not reduce triglyceride concentration in comparison with a lipid-lowering diet. Iron depletion for lipid management in these patients is not supported.
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Affiliation(s)
- Rocío Mateo-Gallego
- Lipid Unit, Hospital Universitario Miguel Servet, IIS Aragon, CIBERCV, Zaragoza, Spain; Universidad de Zaragoza, Zaragoza, Spain
| | - Laura Lacalle
- Hematology Department, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Sofía Pérez-Calahorra
- Lipid Unit, Hospital Universitario Miguel Servet, IIS Aragon, CIBERCV, Zaragoza, Spain
| | - Victoria Marco-Benedí
- Lipid Unit, Hospital Universitario Miguel Servet, IIS Aragon, CIBERCV, Zaragoza, Spain
| | - Valle Recasens
- Universidad de Zaragoza, Zaragoza, Spain; Hematology Department, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Noelia Padrón
- Hematology Department, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Itziar Lamiquiz-Moneo
- Lipid Unit, Hospital Universitario Miguel Servet, IIS Aragon, CIBERCV, Zaragoza, Spain
| | - Lucía Baila-Rueda
- Lipid Unit, Hospital Universitario Miguel Servet, IIS Aragon, CIBERCV, Zaragoza, Spain
| | - Estíbaliz Jarauta
- Lipid Unit, Hospital Universitario Miguel Servet, IIS Aragon, CIBERCV, Zaragoza, Spain
| | - Pilar Calmarza
- Biochemistry Department, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Ana Cenarro
- Lipid Unit, Hospital Universitario Miguel Servet, IIS Aragon, CIBERCV, Zaragoza, Spain
| | - Fernando Civeira
- Lipid Unit, Hospital Universitario Miguel Servet, IIS Aragon, CIBERCV, Zaragoza, Spain; Universidad de Zaragoza, Zaragoza, Spain.
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Harlow KE, Africa JA, Wells A, Belt PH, Behling CA, Jain AK, Molleston JP, Newton KP, Rosenthal P, Vos MB, Xanthakos SA, Lavine JE, Schwimmer JB. Clinically Actionable Hypercholesterolemia and Hypertriglyceridemia in Children with Nonalcoholic Fatty Liver Disease. J Pediatr 2018; 198:76-83.e2. [PMID: 29661561 PMCID: PMC6019181 DOI: 10.1016/j.jpeds.2018.02.038] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 01/19/2018] [Accepted: 02/14/2018] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To determine the percentage of children with nonalcoholic fatty liver disease (NAFLD) in whom intervention for low-density lipoprotein cholesterol or triglycerides was indicated based on National Heart, Lung, and Blood Institute guidelines. STUDY DESIGN This multicenter, longitudinal cohort study included children with NAFLD enrolled in the National Institute of Diabetes and Digestive and Kidney Diseases Nonalcoholic Steatohepatitis Clinical Research Network. Fasting lipid profiles were obtained at diagnosis. Standardized dietary recommendations were provided. After 1 year, lipid profiles were repeated and interpreted according to National Heart, Lung, and Blood Institute Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction. Main outcomes were meeting criteria for clinically actionable dyslipidemia at baseline, and either achieving lipid goal at follow-up or meeting criteria for ongoing intervention. RESULTS There were 585 participants, with a mean age of 12.8 years. The prevalence of children warranting intervention for low-density lipoprotein cholesterol at baseline was 14%. After 1 year of recommended dietary changes, 51% achieved goal low-density lipoprotein cholesterol, 27% qualified for enhanced dietary and lifestyle modifications, and 22% met criteria for pharmacologic intervention. Elevated triglycerides were more prevalent, with 51% meeting criteria for intervention. At 1 year, 25% achieved goal triglycerides with diet and lifestyle changes, 38% met criteria for advanced dietary modifications, and 37% qualified for antihyperlipidemic medications. CONCLUSIONS More than one-half of children with NAFLD met intervention thresholds for dyslipidemia. Based on the burden of clinically relevant dyslipidemia, lipid screening in children with NAFLD is warranted. Clinicians caring for children with NAFLD should be familiar with lipid management.
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Affiliation(s)
- Kathryn E Harlow
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, University of California San Diego School of Medicine, La Jolla, CA; Department of Pediatrics, Division of Gastroenterology, Rady Children's Hospital, San Diego, CA
| | - Jonathan A Africa
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, University of California San Diego School of Medicine, La Jolla, CA; Department of Pediatrics, Division of Gastroenterology, Rady Children's Hospital, San Diego, CA
| | - Alan Wells
- Department of Pediatrics, Division of Dysmorphology and Teratology, University of California, San Diego, CA
| | - Patricia H Belt
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Cynthia A Behling
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, University of California San Diego School of Medicine, La Jolla, CA; Department of Pathology, Sharp Medical Center, San Diego, CA
| | - Ajay K Jain
- Department of Pediatrics, St. Louis University, St. Louis, MO
| | - Jean P Molleston
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Indiana University School of Medicine/Riley Hospital for Children, Indianapolis, IN
| | - Kimberly P Newton
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, University of California San Diego School of Medicine, La Jolla, CA; Department of Pediatrics, Division of Gastroenterology, Rady Children's Hospital, San Diego, CA
| | - Philip Rosenthal
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, University of California, San Francisco Benioff Children's Hospital, San Francisco, CA
| | - Miriam B Vos
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA
| | - Stavra A Xanthakos
- Steatohepatitis Center, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Joel E Lavine
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Columbia University, New York, NY
| | - Jeffrey B Schwimmer
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, University of California San Diego School of Medicine, La Jolla, CA; Department of Pediatrics, Division of Gastroenterology, Rady Children's Hospital, San Diego, CA.
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Masson W, Rossi E, Siniawski D, Damonte J, Halsband A, Barolo R, Scaramal M. Severe hypertriglyceridemia. Clinical characteristics and therapeutic management. Clin Investig Arterioscler 2018; 30:217-223. [PMID: 29789213 DOI: 10.1016/j.arteri.2018.03.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Revised: 03/14/2018] [Accepted: 03/27/2018] [Indexed: 11/18/2022]
Abstract
INTRODUCTION The therapeutic management of severe hypertriglyceridaemia represents a clinical challenge. OBJECTIVES The objectives of this study were 1) to identify the clinical characteristics of patients with severe hypertriglyceridaemia, and 2) to analyse the treatment established by the physicians in each case. METHODS A cross-sectional study was carried out using the computerised medical records of all patients>18 years of age with a blood triglyceride level≥1,000mg/dL between 1 January 2011 and 31 December 2016. Clinical and laboratory variables were collected. The behaviour of the physicians in the 6 months after the lipid finding was analysed. RESULTS A total of 420 patients were included (mean age 49.1±11.4 years, males 78.8%). The median of triglycerides was 1,329mg/dL (interquartile range 1,174-1,658). No secondary causes were found in 34.1% of the patients. The most frequent secondary causes were obesity (38.6%) and diabetes (28.1%). Physical activity was recommended and a nutritionist was referred to in 49.1% and 44.2% of the patients, respectively. Secondary causes were identified and attempts were made to correct them in 40.7% of cases. The most indicated pharmacological treatments were fenofibrate 200mg/day (26.5%) and gemfibrozil 900mg/day (19.3%). Few patients received the indication of omega 3 fatty acids or niacin. CONCLUSION This study showed, for the first time in our country, the characteristics of a population with severe hypertriglyceridaemia. The therapeutic measures instituted by the physicians were insufficient. Knowing the characteristics in this particular clinical scenario could improve the current approach of these patients.
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Affiliation(s)
- Walter Masson
- Servicio de Cardiología, Hospital Italiano de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina.
| | - Emiliano Rossi
- Servicio de Cardiología, Hospital Italiano de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina
| | - Daniel Siniawski
- Servicio de Cardiología, Hospital Italiano de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina
| | - Juan Damonte
- Servicio de Cardiología, Hospital Italiano de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina
| | - Ana Halsband
- Servicio de Cardiología, Hospital Italiano de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina
| | - Ramiro Barolo
- Servicio de Cardiología, Hospital Italiano de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina
| | - Miguel Scaramal
- Servicio de Cardiología, Hospital Italiano de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina
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Berruti A, Gorzegno G, Vitetta G, Tampellini M, Dogliotti L. Hypertriglyceridemia during Long-Term Interferon-Alpha Therapy: Efficacy of Diet and Gemfibrosil Treatment. A Case Report. Tumori 2018; 78:353-5. [PMID: 1494811 DOI: 10.1177/030089169207800515] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Interferon-alpha might increase triglyceride serum levels through the enhancement of hepatic lipogenesis and/or inhibition of the peripheral lipoprotein lipase. Hypertriglyceridemia during interferon-alpha therapy has been only recently described, mostly in patients with previous abnormalities of lipid metabolism. The authors report here a case of a 65-year-old male bearing advanced colon carcinoma who developed hypertriglyceridemia during long-term interferon-alpha treatment in association with 5 fluorouracil administration. Hypertriglyceridemia was maintained within acceptable levels, without adjusting the treatment plan, by an appropriate diet and gemfibrosil administration.
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Affiliation(s)
- A Berruti
- Dipartimento di Scienze Cliniche e Biologiche, Università di Torino, Ospedale S. Luigi Gonzaga, Orbassano, Italy
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Magradze T, Shelestova E. CLINICAL CASE REPORT ON ACUTE PANCREATITIS WITH CONCOMITANT T2DM AND HYPERTRIGLYCERIDEMIA. Georgian Med News 2018:39-44. [PMID: 29745912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Authors present a clinical case review of a 46-years-old, otherwise healthy female patient, presented with acute abdominal pain. Examination and full work-up established a diagnosis of acute pancreatitis, T2DM and hypertriglyceridemia; based on family history, inherited hypertriglyceridemia was suspected. Elevated TG values associated with diabetes dramatically increase the risk of developing MI. Subsequent to the pancreatitis treatment protocol completion, the patient has fully recovered from acute pancreatitis. Prescribed anti-diabetes and Fenofibrate treatment has achieved satisfactory glycemic and TG values. The patient is under close ambulatory control and monitoring at the National Center for Diabetes Research. T2DM and hypertriglyceridemia often coexist. Intensive treatment of both conditions with diet, physical activity, fenofibrates and insulin is important, as it aims to reduce TG values and normalize glucose profile.
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Affiliation(s)
- T Magradze
- National Center for Diabetes Research, Tbilisi, Georgia
| | - E Shelestova
- National Center for Diabetes Research, Tbilisi, Georgia
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Abstract
BACKGROUND Prevention and treatment of dyslipidemias represent the key issues of Cardiovascular Disease (CVD) prophylaxis. Consequently, the effective management of different types of lipid disorders, including hypertriglyceridemia, should be a priority for the healthcare practitioners (e.g.: cardiology and endocrinology specialists, primary care physicians, dietitians, and pharmacists), who provide medical care, as well as for the patients, who receive this care, and need to be directly engaged in it, in order to improve their outcomes. The aim of this review is to facilitate the translation of current trends in hypertriglyceridemia management into a daily practice. The article focuses on the common causes and consequences of hypertriglyceridemia, and discusses diagnostic evaluation and therapeutic options for patients with high Triglyceride (TG) levels and CVD risk. CONCLUSION This review presents the main practice-related strategies, based on the current guidelines for the management of dyslipidemias and CVD risk, according to the European Society of Cardiology (ESC), the European Atherosclerosis Society (EAS), and the American College of Cardiology (ACC)/American Heart Association (AHA), including both non-pharmacological, and pharmacological approaches. It also addresses the beneficial impact of pharmaceutical Care (PC) interventions on clinical outcomes of patients with lipid disorders and CVD risk (in light of Randomized Controlled Trials (RCT) data), and underlines the importance of close cooperation between physicians and pharmacists, who manage such patients.
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Affiliation(s)
- Katarzyna Rygiel
- Department of Family Practice, Medical University of Silesia (SUM), Katowice-Zabrze, Poland
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50
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Abstract
PURPOSE OF REVIEW Intravenous lipid emulsions (IVLEs) are an essential component of parenteral nutrition. With the recent incorporation of new lipid emulsions into the Canadian and American market, the clinician responsible for prescribing these lipids should be educated regarding the different fatty acid (FA) profiles of these lipids, as well as their metabolic and functional effects. RECENT FINDINGS New IVLEs contain a mix of soybean oil and olive oil, or a mix of soybean oil, coconut oil, olive oil and fish oil. These new lipid emulsions provide less essential fatty acids (FAs) (linoleic and alpha linolenic acids) than in pure soybean oil, yet incorporation of fish oil into an IVLE may decrease the amount of essential FAs required. Fish oil is a treatment for hypertriglyceridemia, and therefore, IVLEs that include fish oil may decrease serum triglycerides. Historical perspective is that fish oil can be associated with increased bleeding time. Evidence suggests that there is no association between fish oil and increased bleeding in patients, even those who are using anticoagulants. New IVLEs provide less vitamin K than soybean oil alone. Patients, or the parenteral nutrition solutions that include these new IVLEs should be supplemented with vitamin K. SUMMARY Canadian and American Guidelines for IVLEs were based on soybean oil. Current practice should be tailored to which IVLE is being prescribed.
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Affiliation(s)
- Michele ApSimon
- Critical Care, Cardiac and Vascular and Neuro Trauma Programs, Hamilton General Hospital, Hamilton, Ontario, Canada
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