Skip to main content

Advertisement

SpringerLink
Log in

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

  • Clinical Review
  • Published:
Clinical Journal of Gastroenterology Aims and scope Submit manuscript

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.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. Lankisch PG, Apte M, Banks PA. Acute pancreatitis. Lancet. 2015;386:85–96.

    Article  Google Scholar 

  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.

    Article  Google Scholar 

  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.

    Article  CAS  Google Scholar 

  4. Yadav D, Lowenfels AB. Trends in the epidemiology of the first attack of acute pancreatitis: a systematic review. Pancreas. 2006;33:323–30.

    Article  Google Scholar 

  5. Rawla P, Bandaru SS, Vellipuram AR. Review of infectious etiology of acute pancreatitis. Gastroenterol Res. 2017;10:153–8.

    Article  Google Scholar 

  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.

    Article  CAS  Google Scholar 

  7. Naruse S. Molecular pathophysiology of pancreatitis. Int Med. 2003;42:288–9.

    Article  CAS  Google Scholar 

  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.

    Article  Google Scholar 

  9. Searles GE, Ooi TC. Underrecognition of chylomicronemia as a cause of acute pancreatitis. CMAJ. 1992;147:1806–8.

    CAS  PubMed  PubMed Central  Google Scholar 

  10. Ewald N. Hypertriglyceridemia-induced acute pancreatitis. Clin Lipidol. 2013;8:587–94.

    Article  CAS  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  CAS  Google Scholar 

  13. Zarnescu NO, Barbu ST, Zarnescu Vasiliu EC, et al. Management of acute pancreatitis in the early stage. Maedica. 2015;10:257–63.

    PubMed  PubMed Central  Google Scholar 

  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. 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).

    Article  CAS  Google Scholar 

  16. Khan R, Jehangir W, Regeti K, et al. Hypertriglyceridemia-induced pancreatitis: choice of treatment. Gastroenterol Res. 2015;8:234–6.

    Article  CAS  Google Scholar 

  17. Coskun A, Erkan N, Yakan S, et al. Treatment of hypertriglyceridemia-induced acute pancreatitis with insulin. Przeglad Gastroenterol. 2015;10:18–22.

    CAS  Google Scholar 

  18. Toskes PP. Hyperlipidemic pancreatitis. Gastroenterol Clin N Am. 1990;19:783–91.

    CAS  Google Scholar 

  19. Scherer J, Singh VP, Pitchumoni CS, et al. Issues in hypertriglyceridemic pancreatitis: an update. J Clin Gastroenterol. 2014;48:195–203.

    Article  CAS  Google Scholar 

  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.

    Article  CAS  Google Scholar 

  21. Thuzar M, Shenoy VV, Malabu UH, et al. Extreme hypertriglyceridemia managed with insulin. J Clin Lipidol. 2014;8:630–4.

    Article  Google Scholar 

  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. 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.

    CAS  PubMed  Google Scholar 

  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.

    Article  CAS  Google Scholar 

  25. Eckel RH. Lipoprotein lipase. A multifunctional enzyme relevant to common metabolic diseases. New Engl J Med. 1989;320:1060–8.

    Article  CAS  Google Scholar 

  26. Goldberg IJ. Lipoprotein lipase and lipolysis: central roles in lipoprotein metabolism and atherogenesis. J Lipid Res. 1996;37:693–707.

    CAS  PubMed  Google Scholar 

  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.

    Article  Google Scholar 

  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.

    Article  Google Scholar 

  29. Gray E, Hogwood J, Mulloy B. The anticoagulant and antithrombotic mechanisms of heparin. Handb Exp Pharmacol 2012:43–61.

  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. 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.

    CAS  PubMed  Google Scholar 

  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.

    Article  Google Scholar 

  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.

    Article  CAS  Google Scholar 

  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.

    Article  CAS  Google Scholar 

  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.

    CAS  PubMed  Google Scholar 

  36. Jain D, Zimmerschied J. Heparin and insulin for hypertriglyceridemia-induced pancreatitis: case report. Sci World J. 2009;9:1230–2.

    Article  Google Scholar 

  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.

    Article  CAS  Google Scholar 

  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. Ewald N, Kloer HU. Severe hypertriglyceridemia: an indication for apheresis? Atherosclerosis Suppl. 2009;10:49–52.

    Article  CAS  Google Scholar 

  40. Yeh JH, Chen JH, Chiu HC. Plasmapheresis for hyperlipidemic pancreatitis. J Clin Apheresis. 2003;18:181–5.

    Article  Google Scholar 

  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.

    Article  Google Scholar 

  42. Chait A, Brunzell JD. Chylomicronemia syndrome. Adv Int Med. 1992;37:249–73.

    CAS  Google Scholar 

  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.

    Article  CAS  Google Scholar 

  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.

    Article  CAS  Google Scholar 

  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.

    Article  CAS  Google Scholar 

  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.

    Article  Google Scholar 

  47. Stimac D, Stimac T. Acute pancreatitis during pregnancy. Eur J Gastroenterol Hepatol. 2011;23:839–44.

    Article  Google Scholar 

  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.

    Article  CAS  Google Scholar 

  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.

    Article  Google Scholar 

  50. Serpytis M, Karosas V, Tamosauskas R, et al. Hypertriglyceridemia-induced acute pancreatitis in pregnancy. JOP. 2012;13:677–80.

    PubMed  Google Scholar 

  51. Martin JM, Stapleton RD. Omega-3 fatty acids in critical illness. Nutr Rev. 2010;68:531–41.

    Article  Google Scholar 

  52. Greenberg JA, Bell SJ, Ausdal WV. Omega-3 Fatty Acid supplementation during pregnancy. Rev Obstet Gynecol. 2008;1:162–9.

    PubMed  PubMed Central  Google Scholar 

  53. Basar R, Uzum AK, Canbaz B, et al. Therapeutic apheresis for severe hypertriglyceridemia in pregnancy. Arch Gynecol Obstet. 2013;287:839–43.

    Article  CAS  Google Scholar 

  54. Hang Y, Chen Y, Lu LX, et al. Acute hyperlipidemic pancreatitis in a pregnant woman. World J Emerg Med. 2013;4:311–3.

    Article  Google Scholar 

  55. Ewald N, Kloer HU. Treatment options for severe hypertriglyceridemia (SHTG): the role of apheresis. Clin Res Cardiol Suppl. 2012;7:31–5.

    Article  CAS  Google Scholar 

  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.

    CAS  Google Scholar 

  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.

    Article  Google Scholar 

  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.

    Article  Google Scholar 

  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.

    Article  Google Scholar 

  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.

    Article  Google Scholar 

Download references

Funding

No funding to disclose.

Author information

Authors and Affiliations

  1. Department of Internal Medicine/Hospitalist, SOVAH Health, 320 Hospital Dr, Martinsville, VA, 24115, USA

    Prashanth Rawla

  2. Division of Gastroenterology and Hepatology, The Brooklyn Hospital Center, Clinical Affiliate of the Mount Sinai Hospital, New York, NY, 11201, USA

    Tagore Sunkara

  3. Department of Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA

    Krishna Chaitanya Thandra

  4. Division of Gastroenterology, SBH Health System, Bronx, NY, 19457, USA

    Vinaya Gaduputi

Authors
  1. Prashanth Rawla
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Tagore Sunkara
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Krishna Chaitanya Thandra
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Vinaya Gaduputi
    View author publications

    You can also search for this author in PubMed Google Scholar

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.

Corresponding author

Correspondence to Prashanth Rawla.

Ethics declarations

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.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Rawla, P., Sunkara, T., Thandra, K.C. et al. Hypertriglyceridemia-induced pancreatitis: updated review of current treatment and preventive strategies. Clin J Gastroenterol 11, 441–448 (2018). https://doi.org/10.1007/s12328-018-0881-1

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s12328-018-0881-1

Keywords

Search

Navigation