From the Guidelines
Apheresis is recommended for patients with severe hypertriglyceridemia-induced pancreatitis (HTGP) when triglyceride levels exceed 1000 mg/dL, especially in cases not responding to conventional therapy, as it rapidly removes triglycerides from circulation, reducing levels by 60-80% in a single session, as suggested by the ESPEN guideline on clinical nutrition in acute and chronic pancreatitis 1.
Key Considerations
- The procedure should be initiated within 24-48 hours of diagnosis for optimal effectiveness, with a typical apheresis session lasting 2-4 hours, and daily treatments until triglyceride levels fall below 500 mg/dL, usually requiring 1-3 sessions.
- While undergoing apheresis, patients should receive supportive care including IV fluids, pain management, and fasting to reduce pancreatic stimulation.
- Following acute management, long-term control involves dietary fat restriction (less than 15% of total calories), medication therapy with fibrates (such as fenofibrate 145 mg daily), omega-3 fatty acids (2-4 g daily), and sometimes statins or niacin.
- Apheresis works by physically filtering blood through an extracorporeal circuit that separates and removes triglyceride-rich lipoproteins, providing faster triglyceride reduction than medications alone and potentially reducing inflammation, pancreatic damage, and complications of acute pancreatitis.
Rationale
- The ESPEN guideline on clinical nutrition in acute and chronic pancreatitis 1 suggests that apheresis can be considered if triglycerides still high despite conventional treatment.
- The study by L. Gianotti et al. 1 highlights the importance of treating hypertriglyceridemia in pancreatitis, as it may dramatically improve outcomes and prevent further pancreatic damage.
- Lipoprotein apheresis seems to be more effective than plasma exchange in removing large molecular weight complexes from plasma, such as lipoproteins, while retaining immunoglobulins, albumin, and clotting factors, thus reducing the possibility of infection and bleeding 1.
From the Research
Apheresis in Pancreatitis Caused by Hypertriglycerides
- Apheresis, also known as plasmapheresis, is a treatment option for hypertriglyceridemia-induced pancreatitis, as mentioned in studies 2, 3, 4, 5, 6.
- The goal of apheresis is to lower serum triglyceride levels, which can help alleviate symptoms and prevent further episodes of pancreatitis.
- According to the study 6, administration of insulin, heparin, plasmapheresis, and fibrates can effectively reduce triglyceride levels and relieve symptoms.
- However, as noted in study 5, plasmapheresis has been associated with complications, and its use should be carefully considered.
- The studies 2, 3, 4, 5 suggest that apheresis may be used in conjunction with other treatments, such as insulin, heparin, and fibrates, to manage hypertriglyceridemia-induced pancreatitis.
Treatment Options for Hypertriglyceridemia-Induced Pancreatitis
- The treatment options for hypertriglyceridemia-induced pancreatitis include:
- Supportive care, such as bowel rest, intravenous fluids, and analgesia 2, 3, 4, 5.
- Insulin therapy to lower triglyceride levels 2, 3, 4, 5, 6.
- Heparin infusion to reduce triglyceride levels 3, 5, 6.
- Plasmapheresis to lower triglyceride levels 2, 3, 4, 5, 6.
- Fibrates and omega-3 fatty acids to reduce triglyceride levels 3, 4, 5, 6.
- Dietary modifications and lifestyle changes to prevent further episodes of pancreatitis 3, 4, 5, 6.
Management of Hypertriglyceridemia-Induced Pancreatitis
- The management of hypertriglyceridemia-induced pancreatitis requires a comprehensive approach, including:
- Early identification of hypertriglyceridemia as the cause of pancreatitis 3, 4, 5.
- Initiation of appropriate treatment to lower triglyceride levels 2, 3, 4, 5, 6.
- Supportive care to manage symptoms and prevent complications 2, 3, 4, 5.
- Long-term management to prevent further episodes of pancreatitis, including dietary modifications and lifestyle changes 3, 4, 5, 6.