What is the management of hypertriglyceridemic (elevated triglycerides) pancreatitis?

From the Guidelines

Management of hypertriglyceridemic pancreatitis requires aggressive triglyceride reduction alongside standard pancreatitis care, with initial treatment focusing on NPO status, aggressive IV fluid resuscitation, and adequate pain control, as well as insulin therapy to reduce triglyceride levels below 500 mg/dL. The treatment approach should prioritize reducing triglyceride levels to prevent further pancreatic damage, with the goal of maintaining triglyceride levels within the normal range. According to the most recent guidelines, including the 2021 ACC expert consensus decision pathway 1 and the 2020 ESPEN guideline on clinical nutrition in acute and chronic pancreatitis 1, the management of hypertriglyceridemic pancreatitis involves:

• Initial treatment with NPO status, aggressive IV fluid resuscitation with normal saline at 250-500 mL/hour initially, and adequate pain control with opioid analgesics
• Insulin therapy as the cornerstone of acute management, typically administered as an IV insulin infusion at 0.1-0.3 units/kg/hour with concurrent dextrose infusion to maintain blood glucose between 150-200 mg/dL
• Plasmapheresis may be considered in severe cases with triglycerides >1000 mg/dL or in patients with worsening clinical status despite insulin therapy
• Long-term management includes dietary fat restriction (<20% of total calories), alcohol abstinence, and medications such as fibrates (gemfibrozil 600 mg twice daily or fenofibrate 145 mg daily), omega-3 fatty acids (2-4 g daily), and statins if needed
• The use of fibrates, omega-3 fatty acids, and statins should be guided by the severity of hypertriglyceridemia and the presence of other cardiovascular risk factors, as recommended by the Endocrine Society guidelines 1
• The ESPEN guideline 1 also suggests an algorithm for nutritional management in acute pancreatitis, including the use of enteral nutrition and parenteral nutrition, as well as specific measures for other causes of pancreatitis.

From the FDA Drug Label

Markedly elevated levels of serum triglycerides (e.g., > 2,000 mg/dL) may increase the risk of developing pancreatitis. The effect of fenofibrate therapy on reducing this risk has not been adequately studied.

The management of hypertriglyceridemic pancreatitis may involve reducing serum triglyceride levels, but the effect of fenofibrate on reducing the risk of pancreatitis has not been adequately studied 2.

• Dietary therapy and addressing underlying factors such as excess body weight and excess alcoholic intake should be considered.
• Fenofibrate may be used as adjunctive therapy to diet for the treatment of severe hypertriglyceridemia, but its effect on reducing the risk of pancreatitis is unknown.
• The initial dose of fenofibrate for severe hypertriglyceridemia is 54 mg per day to 160 mg per day, and dosage should be individualized according to patient response.

From the Research

Management of Hypertriglyceridemic Pancreatitis

• The management of hypertriglyceridemic pancreatitis involves conservative treatment, including nothing by mouth, intravenous fluid resuscitation, and analgesia, as well as specific therapies to lower serum triglyceride levels 3, 4, 5.
• Conservative management has been shown to be effective in reducing triglyceride levels, with a mean decrease of 69.8% within 48 hours 4.
• Additional therapies, such as insulin infusion, plasmapheresis, heparin infusion, and hemofiltration, may be used to further reduce triglyceride levels 3, 5, 6, 7.
• Long-term management involves lifestyle modifications, including dietary adjustments and hypolipidemic medications, to prevent further episodes 3, 5, 6, 7.
• Novel agents, such as those that modify the action of lipoprotein lipase, are being studied for the long-term treatment of hypertriglyceridemia 3.
• Genetic testing may be helpful in personalizing management and improving outcomes in some cases 3.

Treatment Options

• Insulin monotherapy has been proposed as a feasible therapeutic option for hypertriglyceridemic pancreatitis 7.
• Plasmapheresis has been used to counteract elevated triglyceride levels, but it has been associated with complications 6.
• Fibric acids and omega-3 fatty acids have been successfully implemented to reduce serum triglycerides 6.
• Heparin infusion and hemofiltration have also been used as additional therapies 5, 7.

Goals of Treatment

• The primary goal of treatment is to reduce and maintain triglyceride levels below 500 mg/dl to prevent recurrent acute pancreatitis 3.
• Treatment should be initiated early to achieve this goal and to reduce the risk of complications 3, 5, 6, 7.