From the Guidelines
Treatment of hypertriglyceridemia-induced pancreatitis requires immediate and aggressive management with fibrates as the first-line treatment, as recommended by the most recent guidelines 1. The first step is to stop oral intake and provide intravenous hydration. Insulin therapy is a cornerstone treatment, typically administered as an intravenous infusion at 0.1-0.3 units/kg/hour along with dextrose to prevent hypoglycemia. This works by enhancing lipoprotein lipase activity, which breaks down triglycerides.
Key Management Strategies
- Plasmapheresis may be considered in severe cases (triglycerides >1000 mg/dL) to rapidly reduce triglyceride levels, as suggested by the ESPEN guideline on clinical nutrition in acute and chronic pancreatitis 1.
- Once the acute phase resolves, long-term management includes fibrates (such as fenofibrate 145 mg daily or gemfibrozil 600 mg twice daily), which can reduce triglycerides by 30-50% 1.
- Omega-3 fatty acids (2-4 g daily) can provide additional benefit, and statins may be added if LDL cholesterol is also elevated 1.
Lifestyle Modifications
- Lifestyle modifications are essential and include a very low-fat diet (<15% of calories from fat), weight loss if overweight, strict alcohol abstinence, and control of diabetes if present, as recommended by the 2021 ACC expert consensus decision pathway on the management of ASCVD risk reduction in patients with persistent hypertriglyceridemia 1.
- Regular monitoring of triglyceride levels is necessary to adjust therapy and prevent recurrence.
- Patients should understand that hypertriglyceridemia-induced pancreatitis has a high recurrence rate without proper management of the underlying lipid disorder.
From the FDA Drug Label
Niacin is also indicated as adjunctive therapy for treatment of adult patients with severe hypertriglyceridemia who present a risk of pancreatitis and who do not respond adequately to a determined dietary effort to control them
- Niacin is indicated for the treatment of severe hypertriglyceridemia with a risk of pancreatitis.
- The treatment should be used as an adjunct to a determined dietary effort.
- Patients should be started with a dose of 500 mg at bedtime and titrated according to patient response, with a recommended maintenance dose of 1000 mg to 2000 mg once daily at bedtime 2.
From the Research
Treatment Options for Hypertriglyceridemia with Pancreatitis
- The treatment of hypertriglyceridemia-induced acute pancreatitis (HTG-AP) involves conservative management, including nothing by mouth, intravenous fluid resuscitation, and analgesia, to achieve triglyceride levels less than 500 mg/dl 3.
- Pharmacological management of hypertriglyceridemia should start early and target triglyceride levels of less than 500 mg/dl to reduce the risk of recurrent acute pancreatitis 3.
- Fenofibrate and omega-3 fatty acids are commonly used to manage hypertriglyceridemia, with novel agents being studied for long-term treatment 3.
- The concomitant use of prescription omega-3 fatty acids (P-OM3) and fenofibrate (FENO) has been shown to result in a greater reduction in triglyceride levels compared to FENO alone 4.
Management of Acute Pancreatitis
- International guidelines on the management of acute pancreatitis recommend the use of lipid-lowering agents, such as fenofibrate, gemfibrozil, niacin, and omega-3 fatty acids, as well as low molecular weight heparin and insulin in diabetic patients 5.
- Plasmapheresis, insulin, heparin infusion, and hemofiltration are additional specific therapies used to lower serum triglyceride levels in acute pancreatitis 6.
- After the acute episode, diet and lifestyle modifications along with hypolipidemic drugs should be initiated to prevent further episodes 6.
Reduction of Triglyceride Levels
- Statins have been shown to reduce mean triglyceride levels by up to 18%, but individuals with hypertriglyceridemia may need additional reduction in triglyceride-rich lipoproteins and remnant particles to further reduce residual cardiovascular disease risk 7.
- Long-chain omega-3 fatty acids may be a well-tolerated and effective alternative to fibrates and niacin for reducing triglyceride levels, but further large-scale clinical studies are required to evaluate their effects on cardiovascular outcomes and disease risk reduction 7.