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 to check access.
Buy single article
Instant unlimited access to the full article PDF.
Price includes VAT for USA
Subscribe to journal
Immediate online access to all issues from 2019. Subscription will auto renew annually.
This is the net price. Taxes to be calculated in checkout.
Lankisch PG, Apte M, Banks PA. Acute pancreatitis. Lancet. 2015;386:85–96.
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.
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.
Yadav D, Lowenfels AB. Trends in the epidemiology of the first attack of acute pancreatitis: a systematic review. Pancreas. 2006;33:323–30.
Rawla P, Bandaru SS, Vellipuram AR. Review of infectious etiology of acute pancreatitis. Gastroenterol Res. 2017;10:153–8.
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.
Naruse S. Molecular pathophysiology of pancreatitis. Int Med. 2003;42:288–9.
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.
Searles GE, Ooi TC. Underrecognition of chylomicronemia as a cause of acute pancreatitis. CMAJ. 1992;147:1806–8.
Ewald N. Hypertriglyceridemia-induced acute pancreatitis. Clin Lipidol. 2013;8:587–94.
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.
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.
Zarnescu NO, Barbu ST, Zarnescu Vasiliu EC, et al. Management of acute pancreatitis in the early stage. Maedica. 2015;10:257–63.
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.
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).
Khan R, Jehangir W, Regeti K, et al. Hypertriglyceridemia-induced pancreatitis: choice of treatment. Gastroenterol Res. 2015;8:234–6.
Coskun A, Erkan N, Yakan S, et al. Treatment of hypertriglyceridemia-induced acute pancreatitis with insulin. Przeglad Gastroenterol. 2015;10:18–22.
Toskes PP. Hyperlipidemic pancreatitis. Gastroenterol Clin N Am. 1990;19:783–91.
Scherer J, Singh VP, Pitchumoni CS, et al. Issues in hypertriglyceridemic pancreatitis: an update. J Clin Gastroenterol. 2014;48:195–203.
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.
Thuzar M, Shenoy VV, Malabu UH, et al. Extreme hypertriglyceridemia managed with insulin. J Clin Lipidol. 2014;8:630–4.
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.
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.
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.
Eckel RH. Lipoprotein lipase. A multifunctional enzyme relevant to common metabolic diseases. New Engl J Med. 1989;320:1060–8.
Goldberg IJ. Lipoprotein lipase and lipolysis: central roles in lipoprotein metabolism and atherogenesis. J Lipid Res. 1996;37:693–707.
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.
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.
Gray E, Hogwood J, Mulloy B. The anticoagulant and antithrombotic mechanisms of heparin. Handb Exp Pharmacol 2012:43–61.
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.
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.
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.
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.
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.
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.
Jain D, Zimmerschied J. Heparin and insulin for hypertriglyceridemia-induced pancreatitis: case report. Sci World J. 2009;9:1230–2.
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.
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.
Ewald N, Kloer HU. Severe hypertriglyceridemia: an indication for apheresis? Atherosclerosis Suppl. 2009;10:49–52.
Yeh JH, Chen JH, Chiu HC. Plasmapheresis for hyperlipidemic pancreatitis. J Clin Apheresis. 2003;18:181–5.
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.
Chait A, Brunzell JD. Chylomicronemia syndrome. Adv Int Med. 1992;37:249–73.
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.
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.
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.
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.
Stimac D, Stimac T. Acute pancreatitis during pregnancy. Eur J Gastroenterol Hepatol. 2011;23:839–44.
Papadakis EP, Sarigianni M, Mikhailidis DP, et al. Acute pancreatitis in pregnancy: an overview. Eur J Obstetr Gynecol Reproduct Biol. 2011;159:261–6.
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.
Serpytis M, Karosas V, Tamosauskas R, et al. Hypertriglyceridemia-induced acute pancreatitis in pregnancy. JOP. 2012;13:677–80.
Martin JM, Stapleton RD. Omega-3 fatty acids in critical illness. Nutr Rev. 2010;68:531–41.
Greenberg JA, Bell SJ, Ausdal WV. Omega-3 Fatty Acid supplementation during pregnancy. Rev Obstet Gynecol. 2008;1:162–9.
Basar R, Uzum AK, Canbaz B, et al. Therapeutic apheresis for severe hypertriglyceridemia in pregnancy. Arch Gynecol Obstet. 2013;287:839–43.
Hang Y, Chen Y, Lu LX, et al. Acute hyperlipidemic pancreatitis in a pregnant woman. World J Emerg Med. 2013;4:311–3.
Ewald N, Kloer HU. Treatment options for severe hypertriglyceridemia (SHTG): the role of apheresis. Clin Res Cardiol Suppl. 2012;7:31–5.
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.
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.
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.
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.
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.
Conflict of interest
Prashanth Rawla, Tagore Sunkara, Krishna Chaitanya Thandra, and Vinaya Gaduputi declare that they have no conflict of interest.
This study does not include any data about human subjects.
This study does not involve human subjects and does not apply to giving Informed Consent.
About this article
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) doi:10.1007/s12328-018-0881-1
- Acute pancreatitis
- Recurrent pancreatitis