Incidence of pancreatitis, secondary causes, and treatment of patients referred to a specialty lipid clinic with severe hypertriglyceridemia: a retrospective cohort study

Abstract

BackgroundSevere hypertriglyceridemia (HTG) is one cause of acute pancreatitis, yet the level of plasma triglycerides likely to be responsible for inducing pancreatitis has not been clearly defined.Methods and ResultsA retrospective cohort study was conducted on patients presenting non-acutely to the Healthy Heart Program Lipid Clinic at St. Paul's Hospital with a TG level > 20 mM (1772 mg/dl) between 1986 and 2007. Ninety-five patients with TG > 20 mM at the time of referral were identified, in who follow up data was available for 84. Fifteen patients (15.8%), with a mean outpatient TG level of 38.1 mM, had a history of acute pancreatitis. Among 91 additional patients with less severe HTG, none had a history of pancreatitis when TG were between 10 and 20 mM. Among patients with TG > 20 mM on presentation, 8 (8.5%), with a mean TG level of 67.8 mM, exhibited eruptive xanthomata. A diet high in carbohydrates and fats (79%) and obesity (47.6%) were the two most frequent secondary causes of HTG at initial visit. By 2009, among patients with follow up data 53% exhibited either pre-diabetes or overt Type 2 diabetes mellitus. Upon referral only 23 patients (24%) were receiving a fibrate as either monotherapy or part of combination lipid-lowering therapy. Following initial assessment by a lipid specialist this rose to 84%, and remained at 67% at the last follow up visit.ConclusionsThese results suggest hypertriglyceridemia is unlikely to be the primary cause of acute pancreatitis unless TG levels are > 20 mM, that dysglycemia, a diet high in carbohydrates and fats, and obesity are the main secondary causes of HTG, and that fibrates are frequently overlooked as the drug of first choice for severe HTG.

Xanthomas: Clinical and pathophysiological relations

“…According to older monographs, eruptive xanthomas can be found in up to 60% of patients with familial chylomicronemia 33 ; this disorder is very rare (1 : 1 million live births). In a group of patients with severe hypertriglyceridemia (characterized by TG >20 mmol/L), 8.5% exhibited eruptive xanthomas and 3% typical forms of xanthoma striatum palmare 36 .…”

“…Eruptive xanthomas are pathognomic skin manifestations of severe hypertriglyceridemia (TG >11.2 mmol/L), a serious metabolic disorder with an estimated prevalence of 18 cases in 100 000 inhabitants 35 . Eruptive xanthoma was retrospectively documented in 10% of patients with severe hypertriglyceridemia 36 . According to older monographs, eruptive xanthomas can be found in up to 60% of patients with familial chylomicronemia 33 ; this disorder is very rare (1 : 1 million live births).…”

EmTriglyceride-Induced Pancreatitis: Diagnostic and Therapeutic Approach

“…These classical findings however, have a very low incidence and are found in only less than 10% of cases. In addition, the triglyceride levels do not accurately predict whether patients would develop these signs, suggesting that factors other than hypertriglyceridemia may contribute to their development [6].…”

“…The prevalence of diabetes among patients with hyper triglyceridemia is 41%, with an additional 11.6% having impaired glucose metabolism. In addition, all patients with hyper triglyceridemia have at least one secondary factor contributing to their hyper triglyceridemia [6].…”

An Interesting Case of Hypertriglyceridaemic Pancreatitis

“…For a long term control and to prevent recurrent pancreatitis the secondary factors like the avoidance of alcohol, weight reduction, the control of diabetes and dietary restrictions with a low fat, low carbohydrate diet should be adopted. Fibrates form the mainstay of the hypertriglyceridaemia treatment [4,10]. These fibrates can reduce the plasma triglyceride levels by up to 50% and raise the plasma HDL-C concentration to as much as 20% [4].…”