From the Guidelines
The treatment for hypertriglyceridemia-induced pancreatitis involves immediate triglyceride reduction and standard pancreatitis management, with a focus on lifestyle interventions including Medical Nutrition Therapy (MNT) and therapies to reduce excesses in both chylomicrons and VLDL.
Key Components of Treatment
- Initially, patients should receive nothing by mouth (NPO), intravenous fluids, pain control, and antiemetics as needed.
- Insulin therapy is a cornerstone treatment, typically administered as an intravenous infusion at 0.1-0.3 units/kg/hour with dextrose to prevent hypoglycemia, continuing until triglyceride levels fall below 500 mg/dL.
- For patients with triglycerides ≥1,000 mg/dL, a very rigorous approach to MNT is advised, with 10% to 15% of calories from fat recommended 1.
- Clinicians may opt to further reduce total fat as a percent of calories in severe cases.
- Plasmapheresis may be considered in severe cases or when insulin therapy is ineffective, removing triglycerides directly from circulation.
Long-term Management
- Once the acute phase resolves, patients should transition to oral medications including fibrates (gemfibrozil 600 mg twice daily or fenofibrate 145 mg daily), statins, and omega-3 fatty acids.
- Long-term management requires dietary modifications with fat restriction, alcohol abstinence, and control of secondary causes like diabetes.
- The goal of these interventions is to reduce the risk of acute pancreatitis and ASCVD in patients with severe hypertriglyceridemia, as elevated triglycerides are associated with an increased risk of these conditions 1.
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
The treatment for hypertriglyceridemia-induced pancreatitis includes niacin extended-release tablets as adjunctive therapy for adult patients with severe hypertriglyceridemia who are at risk of pancreatitis and do not respond to dietary efforts. The dosage should be individualized according to patient response, starting with 500 mg at bedtime and titrating up to a maximum of 2000 mg daily. Dietary effort is also essential in controlling hypertriglyceridemia. Key points to consider:
- Initial dose: 500 mg at bedtime
- Dose escalation: as shown in Table 1, up to a maximum of 2000 mg daily
- Dietary control: essential in managing hypertriglyceridemia 2
From the Research
Treatment Overview
The treatment for hypertriglyceridemia-induced pancreatitis involves a combination of therapies aimed at lowering triglyceride levels and managing symptoms.
- The goal of management is to lower triglyceride levels to less than 500 mg/dL as quickly as possible, as lower levels are associated with good clinical outcomes 3.
- Conventional treatment for acute pancreatitis, including intravenous hydration, is often used in conjunction with other therapies.
Medications
Several medications can be used to treat hypertriglyceridemia-induced pancreatitis, including:
- Insulin: IV regular insulin along with dextrose saline can help lower triglyceride levels 3, 4, 5.
- Heparin: Heparin and insulin can be used together to activate lipoprotein lipase and reduce plasma triglyceride levels 4, 5.
- Fenofibrate: Fenofibrate can be used to lower triglyceride levels, especially in patients with severe hypertriglyceridemia 3, 4.
- Statins: Statins can be used to lower low-density lipoprotein cholesterol levels and reduce triglyceride levels by up to 18% 6.
- Omega-3 fatty acids: Omega-3 fatty acids may be a well-tolerated and effective alternative to fibrates and niacin for reducing triglyceride levels 6.
- Niacin: Niacin can be used to reduce triglyceride levels, but its use is often limited due to side effects 6, 7.
Other Therapies
Other therapies that may be used to treat hypertriglyceridemia-induced pancreatitis include:
- Apheresis: Apheresis can be used to rapidly lower triglyceride levels in patients with severe hypertriglyceridemia 3, 7.
- Lipid apheresis: Lipid apheresis can be used to remove excess lipids from the blood in patients with hypertriglyceridemia-associated acute pancreatitis 4.
- Lifestyle modification: Lifestyle modifications, such as diet and exercise, can help prevent further episodes of pancreatitis and reduce triglyceride levels 3, 7.
Prevention
Preventing further episodes of pancreatitis is crucial in managing hypertriglyceridemia-induced pancreatitis.