eMedicine Specialties > Endocrinology > Metabolic Disorders

Hypertriglyceridemia: Follow-up

Author: Elena Citkowitz, MD, PhD, FACP, Clinical Professor of Medicine, Yale University School of Medicine; Director, Cholesterol Management Center, Director, Cardiac Rehabilitation, Department of Medicine, Hospital of St Raphael
Contributor Information and Disclosures

Updated: Jul 12, 2008

Follow-up

Deterrence/Prevention

  • Patients with hypertriglyceridemia, particularly if the HDL-c level is low, are at risk for cardiovascular events. They should be treated, not only for their lipid disorder, but also for other modifiable cardiovascular risk factors, such as hypertension, diabetes, smoking, sedentary lifestyle, and obesity.
  • While the rare inherited disorders of severe hypertriglyceridemia require heroic restrictions in dietary fat, most elevated triglycerides can be controlled, at least partially, by a program of diet, exercise, and weight loss. Therefore, prevention entails pursuing an active lifestyle with regular aerobic and toning exercise; eating a diet low in simple carbohydrates and alcohol, and if the triglycerides are well above 1000 mg/dL low in fat; and maintaining a lean body habitus. These habits have the added benefit of reducing the probability of developing type 2 diabetes mellitus and hypertension. Lifestyle modification can be more effective than a triglyceride-lowering medication if the habits are in need of intervention and the patient is willing and able to make significant changes.
  • Patients with modest triglyceride elevations may develop severe hypertriglyceridemia and risk of pancreatitis if an aggravating agent is instituted. Drugs such as oral isotretinoin and unopposed oral estrogen replacement therapy should be used with caution.

Complications

  • Triglycerides do not cause complications until elevations of 1000 mg/dL or more are reached. However, as suggested by the NCEP ATP III, triglycerides are so labile that a level between 500 and 1000 mg/dL may in certain settings increase dramatically and should be a target of treatment even before ensuring that the LDL goal is reached.
  • Pancreatitis: Triglycerides do not cause pancreatitis below levels of greater than 1000 mg/dL. However, many patients tolerate triglycerides of 4000 mg/dL or higher without developing symptoms.12
  • The chylomicronemia syndrome
    • The chylomicronemia syndrome, a less recognized diagnosis usually occurring when triglycerides are 800 mg/dL or higher, causes recurrent episodes of ill-defined abdominal pain that may be accompanied by nausea and vomiting.
    • Amylase and lipase levels are normal in this setting.
    • The symptoms resolve when triglycerides are lowered.
    • Other presentations include dyspnea, chest pain, and/or back pain.

Prognosis

  • Patients' risk of cardiovascular disease is diminished with aggressive treatment to lower triglycerides, particularly in the setting of low HDL-c levels.
  • The risk of recurrent pancreatitis secondary to hypertriglyceridemia can be avoided entirely by ensuring that levels are maintained well below 700 mg/dL. Because triglyceride levels are so labile, simply moderating levels to less than 1000 mg/dL does not decrease risk substantially because the slightest metabolic imbalance or dietary indiscretion may push levels several hundred points higher.

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • Failure to treat patients with elevated triglycerides, thereby increasing their risk of pancreatitis or of a cardiovascular event
  • Starting medications that may cause severe hypertriglyceridemia without first checking baseline triglycerides
    • These drugs may be used in patients with mildly elevated triglycerides and are not absolutely contraindicated in patients with significantly elevated triglycerides.
    • Patients must be closely monitored, and a triglyceride-lowering medication should be instituted, if necessary.
  • Combining a statin with either niacin or a fibric acid derivative
    • The increased risk of myositis is not an absolute contraindication except in the case of combining the statin, cerivastatin (recalled from US market 8/8/01), with a fibric acid.
    • A patient with a mixed hyperlipidemia and other risk factors for coronary artery disease may warrant a niacin-statin or gemfibrozil-statin combination when the risks versus benefits are considered.

Special Concerns

  • Pregnancy
    • Women with elevated triglycerides before conception may develop severe hypertriglyceridemia, with triglyceride levels well above 1000 mg/dL, and the concomitant risk of pancreatitis. These women should be counseled regarding diet, exercise, and weight management before becoming pregnant and must be monitored closely during their pregnancies.13 All pregnancies require occasional triglyceride monitoring. Simple inspection to rule out lipemic serum is all that is necessary.
    • Most of the medications to treat hypertriglyceridemia are contraindicated during pregnancy, although treatment with gemfibrozil in a patient with severe hypertriglyceridemia and pancreatitis has been reported. Omega-3 fatty acids may be a more acceptable intervention, but the safety of high-dose N-3 fatty acids has not been proven.
 


More on Hypertriglyceridemia

Overview: Hypertriglyceridemia
Differential Diagnoses & Workup: Hypertriglyceridemia
Treatment & Medication: Hypertriglyceridemia
Follow-up: Hypertriglyceridemia
Multimedia: Hypertriglyceridemia
References
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Further Reading

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Keywords

hTG, chylomicronemia, dysbetalipoproteinemia, familial combined hyperlipoproteinemia, hyperlipidemia, hyperlipoproteinemia, mixed hyperlipidemia, type I hyperlipoproteinemia, type IIb hyperlipoproteinemia, type III hyperlipoproteinemia, type IV hyperlipoproteinemia, type V hyperlipoproteinemia, triglycerides, diabetes mellitus, DM, coronary artery disease, CAD, cardiovascular disease, CVD

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Contributor Information and Disclosures

Author

Elena Citkowitz, MD, PhD, FACP, Clinical Professor of Medicine, Yale University School of Medicine; Director, Cholesterol Management Center, Director, Cardiac Rehabilitation, Department of Medicine, Hospital of St Raphael
Elena Citkowitz, MD, PhD, FACP is a member of the following medical societies: American College of Physicians, American Heart Association, National Lipid Association, and Sigma Xi
Disclosure: Nothing to disclose.

Medical Editor

Steven R Gambert, MD, Program Director, Physician-in-Chief, Professor, Department of Internal Medicine, Sinai Hospital, Johns Hopkins University School of Medicine
Steven R Gambert, MD is a member of the following medical societies: American College of Physicians
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Yoram Shenker, MD, Chief of Endocrinology Section, Veterans Affairs Medical Center of Madison; Interim Chief, Associate Professor, Department of Internal Medicine, Section of Endocrinology, Diabetes and Metabolism, University of Wisconsin at Madison
Yoram Shenker, MD is a member of the following medical societies: American Heart Association, Central Society for Clinical Research, and Endocrine Society
Disclosure: Nothing to disclose.

CME Editor

Mark Cooper, MBBS, PhD, FRACP, Head, Diabetes & Metabolism Division, Baker Heart Research Institute, Professor of Medicine, Monash University
Disclosure: Nothing to disclose.

Chief Editor

George T Griffing, MD, Professor of Medicine, St Louis University School of Medicine
George T Griffing, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Medical Practice Executives, American College of Physician Executives, American College of Physicians, American Diabetes Association, American Federation for Medical Research, American Heart Association, Central Society for Clinical Research, Endocrine Society, International Society for Clinical Densitometry, and Southern Society for Clinical Investigation
Disclosure: Nothing to disclose.

 
 
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