From the Guidelines
Hypertriglyceridemia causes pancreatitis when triglyceride levels exceed 1000 mg/dL, typically becoming a significant risk above 2000 mg/dL, as evidenced by the most recent study 1. The mechanism involves triglyceride-rich lipoproteins being hydrolyzed by pancreatic lipase, releasing free fatty acids that damage pancreatic tissue. These fatty acids form micelles with detergent-like properties that injure acinar cells and capillaries, leading to ischemia and inflammation. Additionally, the increased blood viscosity from high triglyceride levels impairs microcirculation in the pancreas, further contributing to tissue damage. The resulting inflammatory cascade activates pancreatic enzymes prematurely within the pancreas rather than the intestine, causing autodigestion of pancreatic tissue.
Management focuses on rapidly lowering triglyceride levels through:
- Fasting
- Intravenous fluids
- Insulin therapy (typically 0.1-0.3 units/kg/hour)
- Sometimes plasmapheresis for severe cases, as recommended by 1. Long-term prevention requires:
- Dietary fat restriction
- Alcohol avoidance
- Fibrate medications (like fenofibrate 145mg daily)
- Omega-3 fatty acids
- Management of underlying conditions such as diabetes or obesity, as suggested by 1.
It is essential to evaluate for secondary causes of hypertriglyceridemia and consider medical therapy to reduce the risk of pancreatitis in individuals with fasting triglyceride levels ≥500 mg/dL, as stated in 1. Lifestyle interventions, treatment of secondary factors, and avoidance of medications that might raise triglycerides are also recommended for patients with moderate hypertriglyceridemia, as noted in 1.
From the Research
Triglycerdemia and Pancreatitis
- Hypertriglyceridaemia is a common clinical problem that can lead to severe health issues, including pancreatitis 2.
- Severe hypertriglyceridaemia, defined as triglyceride levels ≥500 mg/dL, raises the risk of pancreatitis 2, 3, 4, 5, 6.
- The exact mechanism of how triglycerdemia causes pancreatitis is not fully understood, but it is thought that high levels of triglycerides can cause inflammation and damage to the pancreas.
Risk Factors for Hypertriglyceridemia-Induced Pancreatitis
- Obesity, metabolic syndrome, and type 2 diabetes mellitus are common risk factors for hypertriglyceridemia 4.
- Excessive alcohol use, physical inactivity, being overweight, use of certain medications, and genetic disorders are also risk factors for hypertriglyceridemia 4.
- Patients with hypertriglyceridemia-induced acute pancreatitis (HTG-AP) require early and long-term treatment to reduce triglyceride levels and prevent recurrent acute pancreatitis 5.
Management of Hypertriglyceridemia
- Dietary changes, such as lowering carbohydrate intake and increasing fat and protein intake, can help lower triglyceride levels 4.
- Moderate- to high-intensity physical activity can also lower triglyceride levels and improve body composition and exercise capacity 4.
- Pharmacological management of hypertriglyceridemia, including fenofibrate, omega-3 fatty acids, and novel agents, can help reduce triglyceride levels and prevent pancreatitis 2, 3, 5, 6.
- In some cases, insulin infusion and plasmapheresis may be necessary to manage acute pancreatitis associated with hypertriglyceridemia 4, 5.