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Clinical Journal of Gastroenterology

, Volume 11, Issue 6, pp 441–448 | Cite as

Hypertriglyceridemia-induced pancreatitis: updated review of current treatment and preventive strategies

  • Prashanth Rawla
  • Tagore Sunkara
  • Krishna Chaitanya Thandra
  • Vinaya Gaduputi
Clinical Review

Abstract

Hypertriglyceridemia (HTG) is an uncommon but well-established cause of acute pancreatitis (AP) comprising up to 7% of the cases. The clinical course of HTG-induced pancreatitis (HTGP) is highly similar to that of AP of other etiologies with HTG being the only distinguishing clinical feature. However, HTGP is often correlated with higher severity and elevated complication rate. At present, no approved treatment guideline for the management of HTGP is available, although different treatment modalities such as insulin, heparin, fibric acids, and omega 3 fatty acids have been successfully implemented to reduce serum triglycerides (TG). Plasmapheresis has also been used to counteract elevated TG levels in HTGP patients. However, it has been associated with complications. Following the management of acute phase, lifestyle modifications including dietary adjustments and drug therapy are essential in the long-term management of HTGP and the prevention of its relapse. Results from studies of small patient groups describing treatment and prevention of HTGP are not sufficient to draw solid conclusions resulting in no treatment algorithm being available for effective management of HTGP. Therefore, prospective randomized, active-controlled clinical studies are required to find a better treatment regimen for the management of HTGP. Until date, one randomized clinical trial has been performed to compare clinical outcomes of different treatment approaches for HTGP. However, further studies are required to outline a generalized and efficient treatment regimen for the management of HTGP.

Keywords

Hypertriglyceridemia Acute pancreatitis Insulin Heparin Plasmapheresis Recurrent pancreatitis 

Notes

Author Contributions

Conception and design: PR, M.D; TS, M.D. Analysis and interpretation: PR, M.D; TS, M.D; KCT, M.D, VG, M.D. Drafting of the article: PR, M.D; TS, M.D; KCT, M.D, VG, M.D. Critical revision of the article: PR, M.D; TS, M.D; KCT, M.D, VG, M.D. Final approval of the article: PR, M.D; TS, M.D; KCT, M.D, VG, M.D.

Funding

No funding to disclose.

Compliance with ethical standards

Conflict of interest

Prashanth Rawla, Tagore Sunkara, Krishna Chaitanya Thandra, and Vinaya Gaduputi declare that they have no conflict of interest.

Human/animal rights

This study does not include any data about human subjects.

Informed consent

This study does not involve human subjects and does not apply to giving Informed Consent.

References

  1. 1.
    Lankisch PG, Apte M, Banks PA. Acute pancreatitis. Lancet. 2015;386:85–96.CrossRefGoogle Scholar
  2. 2.
    Xiao AY, Tan ML, Wu LM, et al. Global incidence and mortality of pancreatic diseases: a systematic review, meta-analysis, and meta-regression of population-based cohort studies. Lancet Gastroenterol Hepatol. 2016;1:45–55.CrossRefGoogle Scholar
  3. 3.
    Carr RA, Rejowski BJ, Cote GA, et al. Systematic review of hypertriglyceridemia-induced acute pancreatitis: a more virulent etiology? Pancreatol Off J Int Assoc Pancreatol. 2016;16:469–76.CrossRefGoogle Scholar
  4. 4.
    Yadav D, Lowenfels AB. Trends in the epidemiology of the first attack of acute pancreatitis: a systematic review. Pancreas. 2006;33:323–30.CrossRefGoogle Scholar
  5. 5.
    Rawla P, Bandaru SS, Vellipuram AR. Review of infectious etiology of acute pancreatitis. Gastroenterol Res. 2017;10:153–8.CrossRefGoogle Scholar
  6. 6.
    Saluja AK, Donovan EA, Yamanaka K, et al. Cerulein-induced in vitro activation of trypsinogen in rat pancreatic acini is mediated by cathepsin B. Gastroenterology. 1997;113:304–10.CrossRefGoogle Scholar
  7. 7.
    Naruse S. Molecular pathophysiology of pancreatitis. Int Med. 2003;42:288–9.CrossRefGoogle Scholar
  8. 8.
    Kota SK, Kota SK, Jammula S, et al. Hypertriglyceridemia-induced recurrent acute pancreatitis: a case-based review. Indian J Endocrinol Metab. 2012;16:141–3.CrossRefGoogle Scholar
  9. 9.
    Searles GE, Ooi TC. Underrecognition of chylomicronemia as a cause of acute pancreatitis. CMAJ. 1992;147:1806–8.PubMedPubMedCentralGoogle Scholar
  10. 10.
    Ewald N. Hypertriglyceridemia-induced acute pancreatitis. Clin Lipidol. 2013;8:587–94.CrossRefGoogle Scholar
  11. 11.
    Adiamah A, Psaltis E, Crook M, et al. A systematic review of the epidemiology, pathophysiology and current management of hyperlipidaemic pancreatitis. Clin Nutr. 2017.  https://doi.org/10.1016/j.clnu.2017.09.028.CrossRefPubMedGoogle Scholar
  12. 12.
    Anderson F, Thomson SR, Clarke DL, et al. Dyslipidaemic pancreatitis clinical assessment and analysis of disease severity and outcomes. Pancreatol Off J Int Assoc Pancreatol. 2009;9:252–7.CrossRefGoogle Scholar
  13. 13.
    Zarnescu NO, Barbu ST, Zarnescu Vasiliu EC, et al. Management of acute pancreatitis in the early stage. Maedica. 2015;10:257–63.PubMedPubMedCentralGoogle Scholar
  14. 14.
    Lebenson J, Oliver T. Hypertriglyceride induced acute pancreatitis. Prof. Luis Rodrigo (Ed.), ISBN: 978-953-307-984-4, InTech, Available from: http://www.intechopen.com/books/acute-pancreatitis/hypertriglyceride-induced-acute-pancreatitis. 2012. Accessed 3 Apr 2018.
  15. 15.
    Tenner S, Baillie J, DeWitt J, et al. American College of Gastroenterology guideline: management of acute pancreatitis. Am J Gastroenterol. 2013;108:1400–15 (1416).CrossRefGoogle Scholar
  16. 16.
    Khan R, Jehangir W, Regeti K, et al. Hypertriglyceridemia-induced pancreatitis: choice of treatment. Gastroenterol Res. 2015;8:234–6.CrossRefGoogle Scholar
  17. 17.
    Coskun A, Erkan N, Yakan S, et al. Treatment of hypertriglyceridemia-induced acute pancreatitis with insulin. Przeglad Gastroenterol. 2015;10:18–22.Google Scholar
  18. 18.
    Toskes PP. Hyperlipidemic pancreatitis. Gastroenterol Clin N Am. 1990;19:783–91.Google Scholar
  19. 19.
    Scherer J, Singh VP, Pitchumoni CS, et al. Issues in hypertriglyceridemic pancreatitis: an update. J Clin Gastroenterol. 2014;48:195–203.CrossRefGoogle Scholar
  20. 20.
    Hooper L, Thompson RL, Harrison RA, et al. Risks and benefits of omega 3 fats for mortality, cardiovascular disease, and cancer: systematic review. BMJ. 2006;332:752–60.CrossRefGoogle Scholar
  21. 21.
    Thuzar M, Shenoy VV, Malabu UH, et al. Extreme hypertriglyceridemia managed with insulin. J Clin Lipidol. 2014;8:630–4.CrossRefGoogle Scholar
  22. 22.
    Afari ME, Shafqat H, Shafi M, et al. Hypertriglyceridemia-induced pancreatitis: a decade of experience in a community-based teaching hospital. Rhode Island Med J. 2015;98:40–3.Google Scholar
  23. 23.
    Berger Z, Quera R, Poniachik J, et al. Heparin and insulin treatment of acute pancreatitis caused by hypertriglyceridemia. Experience of 5 cases]. Revista Medica de Chile. 2001;129:1373–8.PubMedGoogle Scholar
  24. 24.
    Syed H, Bilusic M, Rhondla C, et al. Plasmapheresis in the treatment of hypertriglyceridemia-induced pancreatitis: a community hospital’s experience. J Clin Apheresis. 2010;25:229–34.CrossRefGoogle Scholar
  25. 25.
    Eckel RH. Lipoprotein lipase. A multifunctional enzyme relevant to common metabolic diseases. New Engl J Med. 1989;320:1060–8.CrossRefGoogle Scholar
  26. 26.
    Goldberg IJ. Lipoprotein lipase and lipolysis: central roles in lipoprotein metabolism and atherogenesis. J Lipid Res. 1996;37:693–707.PubMedGoogle Scholar
  27. 27.
    Poonuru S, Pathak SR, Vats HS, et al. Rapid reduction of severely elevated serum triglycerides with insulin infusion, gemfibrozil and niacin. Clin Med Res. 2011;9:38–41.CrossRefGoogle Scholar
  28. 28.
    Mikhail N, Trivedi K, Page C, et al. Treatment of severe hypertriglyceridemia in nondiabetic patients with insulin. Am J Emerg Med. 2005;23:415–7.CrossRefGoogle Scholar
  29. 29.
    Gray E, Hogwood J, Mulloy B. The anticoagulant and antithrombotic mechanisms of heparin. Handb Exp Pharmacol 2012:43–61.Google Scholar
  30. 30.
    Maccia M. Mechanism for Heparin’s ability to lower TGs in hypertriglyceridemia. 2015. https://www.ebmconsult.com/articles/heparin-mechanism-reduce-triglycerides-hypertriglyceridemia-treatment. Accessed on 02 April 2018.
  31. 31.
    Korn ED. Clearing factor, a heparin-activated lipoprotein lipase. I. Isolation and characterization of the enzyme from normal rat heart. J Biol Chem. 1955;215:1–14.PubMedGoogle Scholar
  32. 32.
    Kuchay MS, Farooqui KJ, Bano T, et al. Heparin and insulin in the management of hypertriglyceridemia-associated pancreatitis: case series and literature review. Arch Endocrinol Metab. 2017;61:198–201.CrossRefGoogle Scholar
  33. 33.
    Nasstrom B, Olivecrona G, Olivecrona T, et al. Lipoprotein lipase during continuous heparin infusion: tissue stores become partially depleted. J Lab Clin Med. 2001;138:206–13.CrossRefGoogle Scholar
  34. 34.
    Watts GF, Cameron J, Henderson A, et al. Lipoprotein lipase deficiency due to long-term heparinization presenting as severe hypertriglyceridaemia in pregnancy. Postgrad Med J. 1991;67:1062–4.CrossRefGoogle Scholar
  35. 35.
    Henzen C, Rock M, Schnieper C, et al. Heparin and insulin in the treatment of acute hypertriglyceridemia-induced pancreatitis. Schweizerische medizinische Wochenschrift. 1999;129:1242–8.PubMedGoogle Scholar
  36. 36.
    Jain D, Zimmerschied J. Heparin and insulin for hypertriglyceridemia-induced pancreatitis: case report. Sci World J. 2009;9:1230–2.CrossRefGoogle Scholar
  37. 37.
    Click B, Ketchum AM, Turner R, et al. The role of apheresis in hypertriglyceridemia-induced acute pancreatitis: a systematic review. Pancreatol Off J Int Assoc Pancreatol. 2015;15:313–20.CrossRefGoogle Scholar
  38. 38.
    Gavva C, Sarode R, Agrawal D, et al. Therapeutic plasma exchange for hypertriglyceridemia induced pancreatitis: a rapid and practical approach. Transfus Apheresis Sci Off J World Apheresis Assoc Off J Eur Soc Haemapheresis. 2016;54:99–102.Google Scholar
  39. 39.
    Ewald N, Kloer HU. Severe hypertriglyceridemia: an indication for apheresis? Atherosclerosis Suppl. 2009;10:49–52.CrossRefGoogle Scholar
  40. 40.
    Yeh JH, Chen JH, Chiu HC. Plasmapheresis for hyperlipidemic pancreatitis. J Clin Apheresis. 2003;18:181–5.CrossRefGoogle Scholar
  41. 41.
    Yeh JH, Lee MF, Chiu HC. Plasmapheresis for severe lipemia: comparison of serum-lipid clearance rates for the plasma-exchange and double-filtration variants. J Clin Apheresis. 2003;18:32–6.CrossRefGoogle Scholar
  42. 42.
    Chait A, Brunzell JD. Chylomicronemia syndrome. Adv Int Med. 1992;37:249–73.Google Scholar
  43. 43.
    Lennertz A, Parhofer KG, Samtleben W, et al. Therapeutic plasma exchange in patients with chylomicronemia syndrome complicated by acute pancreatitis. Therap Apheresis Off J Int Soc Apheresis Jpn Soc Apheresis. 1999;3:227–33.CrossRefGoogle Scholar
  44. 44.
    Piolot A, Nadler F, Cavallero E, et al. Prevention of recurrent acute pancreatitis in patients with severe hypertriglyceridemia: value of regular plasmapheresis. Pancreas. 1996;13:96–9.CrossRefGoogle Scholar
  45. 45.
    He WH, Yu M, Zhu Y, et al. Emergent triglyceride-lowering therapy with early high-volume hemofiltration against low-molecular-weight heparin combined with insulin in hypertriglyceridemic pancreatitis: a prospective randomized controlled trial. J Clin Gastroenterol. 2016;50:772–8.CrossRefGoogle Scholar
  46. 46.
    Miyamoto K, Horibe M, Sanui M, et al. Plasmapheresis therapy has no triglyceride-lowering effect in patients with hypertriglyceridemic pancreatitis. Intensive Care Med. 2017;43:949–51.CrossRefGoogle Scholar
  47. 47.
    Stimac D, Stimac T. Acute pancreatitis during pregnancy. Eur J Gastroenterol Hepatol. 2011;23:839–44.CrossRefGoogle Scholar
  48. 48.
    Papadakis EP, Sarigianni M, Mikhailidis DP, et al. Acute pancreatitis in pregnancy: an overview. Eur J Obstetr Gynecol Reproduct Biol. 2011;159:261–6.CrossRefGoogle Scholar
  49. 49.
    Altun D, Eren G, Cukurova Z, et al. An alternative treatment in hypertriglyceridemia-induced acute pancreatitis in pregnancy: plasmapheresis. J Anaesthesiol Clin Pharmacol. 2012;28:252–4.CrossRefGoogle Scholar
  50. 50.
    Serpytis M, Karosas V, Tamosauskas R, et al. Hypertriglyceridemia-induced acute pancreatitis in pregnancy. JOP. 2012;13:677–80.PubMedGoogle Scholar
  51. 51.
    Martin JM, Stapleton RD. Omega-3 fatty acids in critical illness. Nutr Rev. 2010;68:531–41.CrossRefGoogle Scholar
  52. 52.
    Greenberg JA, Bell SJ, Ausdal WV. Omega-3 Fatty Acid supplementation during pregnancy. Rev Obstet Gynecol. 2008;1:162–9.PubMedPubMedCentralGoogle Scholar
  53. 53.
    Basar R, Uzum AK, Canbaz B, et al. Therapeutic apheresis for severe hypertriglyceridemia in pregnancy. Arch Gynecol Obstet. 2013;287:839–43.CrossRefGoogle Scholar
  54. 54.
    Hang Y, Chen Y, Lu LX, et al. Acute hyperlipidemic pancreatitis in a pregnant woman. World J Emerg Med. 2013;4:311–3.CrossRefGoogle Scholar
  55. 55.
    Ewald N, Kloer HU. Treatment options for severe hypertriglyceridemia (SHTG): the role of apheresis. Clin Res Cardiol Suppl. 2012;7:31–5.CrossRefGoogle Scholar
  56. 56.
    Nasa P, Alexander G, Kulkarni A, et al. Early plasmapheresis in patients with severe hypertriglyceridemia induced acute pancreatitis. Indian J Crit Care Med Peer Rev Off Publ Indian Soc Crit Care Med. 2015;19:487–9.Google Scholar
  57. 57.
    Huang C, Liu J, Lu Y, et al. Clinical features and treatment of hypertriglyceridemia-induced acute pancreatitis during pregnancy: a retrospective study. J Clin Apheresis. 2016;31:571–8.CrossRefGoogle Scholar
  58. 58.
    Kris-Etherson PM, Pearson TA, Wan Y, et al. High-monounsaturated fatty acid diets lower both plasma cholesterol and triacylglycerol concentrations. Am J Clin Nutr. 1999;70:1009–15.CrossRefGoogle Scholar
  59. 59.
    Christian JB, Arondekar B, Buysman EK, et al. Clinical and economic benefits observed when follow-up triglyceride levels are less than 500 mg/dL in patients with severe hypertriglyceridemia. J Clin Lipidol. 2012;6:450–61.CrossRefGoogle Scholar
  60. 60.
    Expert Panel on Detection E, and Treatment of High Blood Cholesterol in Adults. Executive Summary of The Third Report of The National Cholesterol Education Program (NCEP). Expert panel on detection, evaluation, and treatment of high blood cholesterol in adults (adult treatment panel III). JAMA 2001;285:2486–97.CrossRefGoogle Scholar

Copyright information

© Japanese Society of Gastroenterology 2018

Authors and Affiliations

  1. 1.Department of Internal Medicine/HospitalistSOVAH HealthMartinsvilleUSA
  2. 2.Division of Gastroenterology and Hepatology, The Brooklyn Hospital CenterClinical Affiliate of the Mount Sinai HospitalNew YorkUSA
  3. 3.Department of Critical Care MedicineMemorial Sloan Kettering Cancer CenterNew YorkUSA
  4. 4.Division of GastroenterologySBH Health SystemBronxUSA

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