Patients with very high levels of serum triglycerides (greater than 1000 mg/dL) are at risk for pancreatitis. The pathophysiology is not certain, since pancreatitis never develops in some patients with very high triglyceride levels. Most patients with congenital abnormalities in triglyceride metabolism present in childhood; hypertriglyceridemia-induced pancreatitis first presenting in adults is more commonly due to an acquired problem in lipid metabolism.
Although there are no clear triglyceride levels that predict pancreatitis, most clinicians treat fasting levels above 500 mg/dL (5 mmol/L). The risk of pancreatitis may be more related to the triglyceride level following consumption of a fatty meal. Because postprandial increases in triglyceride are inevitable if fat-containing foods are eaten, fasting triglyceride levels in persons prone to pancreatitis should be kept well below that level.
The primary therapy for high triglyceride levels is dietary, avoiding alcohol, simple sugars, refined starches, and saturated and trans fatty acids, and restricting total calories. Control of secondary causes of high triglyceride levels (see eTable 28–1) may also be helpful. In patients with fasting triglycerides greater than or equal to 500 mg/dL (5 mmol/L) despite adequate dietary compliance—and certainly in those with a previous episode of pancreatitis—therapy with a triglyceride-lowering drug (eg, statins, omega-3 preparations, or fibric acid derivatives) is indicated. Combinations of these medications may also be used.
Currently, drug treatment for patients with triglycerides greater than 150 mg/dL (1.5 mmol/L) is reserved for those with established CVD with well-controlled LDL cholesterol on maximally tolerated therapy with statins or other agents. Currently, data are strongest for icosapent ethyl.
et al; REDUCE-IT Investigators. Cardiovascular risk reduction with icosapent ethyl for hypertriglyceridemia. N Engl J Med. 2019 Jan 3;380(1):11–22.
et al. Pharmacological treatment options for severe hypertriglyceridemia and familial chylomicronemia syndrome. Expert Rev Clin Pharmacol. 2018 Jun;11(6):589–98.
et al. Triglyceride-rich lipoproteins and remnants: targets for therapy? Curr Cardiol Rep. 2016 Jul;18(7):67.
et al. National Lipid Association Scientific Statement on the use of icosapent ethyl in statin-treated patients with elevated triglycerides and high or very-high ASCVD risk. J Clin Lipidol. 2019 Nov–Dec;13(6):860–72.
K. Hypertriglyceridemia—common causes, prevention and treatment strategies. Curr Cardiol Rev. 2018 Mar 14;14(1):67–76.
et al. Remnant-like particle cholesterol, low-density lipoprotein triglycerides, and incident cardiovascular disease. J Am Coll Cardiol. 2018 Jul 10;72(2):156–69.
et al. Triglycerides: a reappraisal. Trends Cardiovasc Med. 2017 Aug;27(6):428–32.