Transcript 3. Triglyceridesx

TRIGLYCERIDES
HYPERTRIGLYCERIDEMIA
Classification
TG level, mg/dL
Normal triglyceride level
< 150
Borderline-high
triglyceride level
150-199
High triglyceride level
200-499
Very high triglyceride
level
>500
Source: National Cholesterol Education Program. 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. May 16 2001;285(19):2486-97.[14]
Gastrointestinal symptoms
Hypertriglyceridemia is usually asymptomatic
until triglycerides are greater than 1000-2000
mg/dL. Patients may report pain, which is
commonly mid epigastric but may occur in
other regions, including the chest or back.
A history of recurrent episodes of acute
pancreatitis is common in patients with
severe and uncontrolled
hypertriglyceridemia.Triglyceride levels often
exceed 5000 mg/dL at the onset of
pancreatitis.
Dermatologic symptoms
Severe hypertriglyceridemia may cause skin
lesions called xanthomas. Patients may report the
appearance of any of the following types of
xanthomas:
•Xanthoma striata palmaris: Orange-yellow
discolorations of the palmar creases, which in
some cases are raised; considered pathognomonic
for dysbetalipoproteinemia
•Tuberoeruptive xanthomas: Nonpainful, raised,
erythematous, nodular lesions approximately 0.5
cm in diameter; may be present on the elbows
and knees
•Xanthoma striata palmaris: Orange-yellow discolorations of the palmar creases,
which in some cases are raised; considered pathognomonic for
dysbetalipoproteinemia
Dermatologic symptoms
Tuberous xanthomas: Larger, coalesced
tuberoeruptive xanthomas; raised, moderately
firm, nontender lesions predominantly on the
elbows and knees
Tendon xanthomas: Occur infrequently; more
common in familial hypercholesterolemia
Eruptive xanthomas: Small nodular papules
commonly seen over the trunk, buttocks, and
thighs; associated with chylomicronemia
syndrome
Eruptive xanthomas on the back of a patient admitted
with a triglyceride level of 4600 mg/dL and acute
pancreatitis
Uncommonly,
patients
may also note the
presence of a corneal
arcus, which is a grayish
white opacification at the
periphery of the cornea
and/or
Ophthalmologic
symptoms
xanthelasmas, which are pale yellow, raised
lesions around the eyelids.
Diagnostic Considerations
When triglycerides are noted to be elevated,
always check a fasting blood sugar and
HbA1c to rule out uncontrolled diabetes—
one of the most frequent causes of
hypertriglyceridemia. Management of this
condition may make medication to lower the
triglycerides unnecessary or, at least, make it
easier to normalize.
A diet high in refined carbohydrates can
cause hypertriglyceridemia. Although
cakes, candy, cookies, etc, are an obvious
source, the quantity of liquid calories
(nondiet soda, juice, alcohol) should also
be determined.
In addition, consider conditions such as
hypertriglyceridemia with elevations of very
low-density lipoprotein (VLDL) with or
without chylomicronemia, as well as mixed
hyperlipidemia (type IIb hyperlipidemia)
with elevations of both low-density
lipoprotein (LDL) and VLDL. Note : use of
oral contraceptives, beta-blockers, and
thiazide diuretics can also raise plasma
triglyceride and VLDL levels.
Pharmacologic Therapy
Niacin
High-dose niacin (vitamin B-3) (1500 or more
mg/d) decreases triglyceride levels by at least
40% and can raise HDL cholesterol levels by
40% or more.
Fibrates
Omega acids
Omega-3 fatty acids are attractive because of their low
risk of major adverse effects or interaction with other
medications. At high doses (≥4 g/d), triglycerides are
reduced. A minimum dose of 4 g of omega-3 fatty
acids per day may require at least 8-12 capsules.
Low doses of EPA and DHA (750-1000 mg/d) that do
not affect lipid levels have been demonstrated to lower
the increased TG-lowering therapies (eg, fibrates, fish oils
containing both EPA and DHA) can substantially increase
LDL cholesterol levels in patients with severe
hypertriglyceridemia (≥500 mg/dL).
HMG-CoA reductase inhibitors (statins)
Note the following :
Statins are more effective when taken at
bedtime or in the evening.
A major reduction in HDL may occur in
some patients on combined therapy with
fibrates and thiazolidinediones (check HDL
levels 1-2 months following initiation of this
combination therapy)