Hypertriglyceridemia-induced acute pancreatitis

TG 長期控制的目標在 200 以下. 
TG上升造成胰臟發炎. 超過 1000 以上可考慮血漿置換. 治療目標, 將TG降至 500 以下. 如果無法使用血漿置換. 可使用靜脈注射胰島素. 劑量 0.1-0.3u/kg/hr. 以 60 公斤重成人為例, 每小時 6-18u,
胰島素治療需每小時測血糖. 每 12 小時測量 TG. 治療目標也是將TG降到 500 以下. 
其他治療方式與別的成因的胰臟炎相同: 空腹, 補充輸液, 止痛




Apheresis

分離術. 將血液某個成分使用機器分離移除.

https://www.uptodate.com/contents/hypertriglyceridemia-induced-acute-pancreatitis#H8

Hypertriglyceridemia-induced acute pancreatitis

Hypertriglyceridemia (HTG)

Severe HTG (1000 to 1999 mg/dL, 11.3 to 22.5 mmol/L)

Risk of acute pancreatitis — Mild hypertriglyceridemia is associated with a low risk of acute pancreatitis [2,9-11]. The risk increases progressively with serum triglyceride levels over 500 mg/dL (5.6 mmol/L) with the risk increasing markedly with levels over 1000 mg/dL (11.3 mmol/L) [10,12,13]. The risk of developing acute pancreatitis is approximately 5 percent with serum triglycerides >1000 mg/dL (11.3 mmol/L) and 10 to 20 percent with triglycerides >2000 mg/dL (22.6 mmol/L) 

Secondary hypertriglyceridemia — Various conditions can raise triglycerides and lead to HTGP.

Diabetes mellitus 

Medications 

Pregnancy 

Alcohol 

Hypothyroidism

Treatment of acute pancreatitis — Initial management of a patient with acute pancreatitis consists of supportive care with fluid resuscitation, pain control, and nutritional support. The management of acute pancreatitis is discussed in detail separately. Patients with worrisome features — In patients with HTGP and one or more worrisome feature, we suggest initial therapy with therapeutic plasma exchange (TPE) [48,49].

需注意是否合併低血鈣. 是否乳酸中毒. 是否出現全身性發炎反應 SIRS. 是否出現器官功能異常. 或多重器官衰竭. 

Worrisome features in patients with HTGP include the following:

●Signs of hypocalcemia

●Lactic acidosis

●Signs of worsening systemic inflammation (two or more):

•Temperature >38.5°C or <35.0°C

•Heart rate of >90 beats/min

•Respiratory rate of >20 breaths/min or PaCO2 of <32 mmHg

•WBC count of >12,000 cells/mL, <4000 cells/mL, or >10 percent immature (band) forms

●Signs of worsening organ dysfunction or multi-organ failure as defined by Modified Marshall scoring system for organ dysfunction (table 1) 

We administer intravenous insulin if apheresis is unavailable or if the patient cannot tolerate apheresis.

Patients without worrisome features — In patients with acute pancreatitis without worrisome features, we administer intravenous insulin. For management of hypertriglyceridemia, insulin is continued until triglyceride levels are <500 mg/dL

Treatment modalities

Apheresis — Apheresis is the process of passing blood through a medical device to separate any components, and returning the remaining components to the body. TPE is the modality of choice for apheresis in patients with HTGP. The process of TPE involves the removal of plasma and replacement with a colloid solution (eg, albumin or plasma) [50].

We use citrate as an anticoagulant rather than heparin and initiate apheresis as soon as possible [51]. However, the benefit of early initiation has not been consistently demonstrated [51,52]. In an observational cohort study that included 103 patients with 111 episodes of hypertriglyceridemic pancreatitis, citrate anticoagulation during plasmapheresis as compared with heparin was associated with a significantly lower mortality (1 versus 11 percent). Citrate anticoagulation was an independent predictor of survival [52]. Studies comparing TPE replacement fluid (albumin versus fresh frozen plasma) in patients with HTGP are lacking.

We use apheresis only in selected patients with severe HTGP as there are significant concerns surrounding apheresis including its cost, availability, and efficacy [53,54]. The efficacy of TPE in reducing the severity of hypertriglyceridemia-induced acute pancreatitis or other clinical important endpoints such as mortality has not been established. In addition, the evidence to support the use of apheresis in patients with HTGP is from observational studies, and randomized trials are lacking [47,53-66]. One study comparing outcomes in 20 TPE-treated patients with historic controls found no difference between standard therapy and TPE with regard to mortality or systemic complications [58].

Insulin — We typically initiate an intravenous (IV) infusion of regular insulin at a rate of 0.1 to 0.3 units/kg/hour. In patients with blood glucose levels between 150 and 200 mg/dL, we administer a separate 5 percent dextrose infusion to prevent hypoglycemia due to the insulin infusion.

使用胰島素治療可在 3.5天~4天內將TG降下來. 靜脈注射會比皮下注射效果好. 

Many insulin regimens have been reported to lower triglyceride levels to less than 500 mg/dL (5.6 mmol/L) over 3.5 to 4 days [44-46]. IV insulin may be more effective than subcutaneous insulin in severe cases of HTGP [44,45]. Insulin decreases serum triglyceride levels by enhancing lipoprotein lipase activity, an enzyme that accelerates chylomicron and very low-density lipoprotein metabolism to glycerol and fatty free acids [67,68]. Insulin also inhibits hormone-sensitive lipase in adipocytes, which is the key enzyme for breaking down adipocyte triglyceride and releasing free fatty acids (FFA) into the circulation. Because HTGP often presents in patients with uncontrolled diabetes, insulin can decrease both triglyceride and glucose levels.

Monitoring and duration of therapy

血漿置換的病患. 每次洗完都應測量TG. 可重複操作至 TG < 500. 

●In patients treated with apheresis, triglycerides should be measured after each cycle of apheresis. We continue apheresis until triglyceride levels are below <500 mg/dL (5.6 mmol/L). One series of seven patients with an average triglyceride level of 1407 mg/dL (15.8 mmol/L) reported a decrease in mean triglyceride levels to 683 mg/dL (51 percent) after one plasma exchange session [60]. In another case report, triglycerides were lowered from 2410 (27.2 mmol/L) to 138 mg/dL (1.5 mmol/L) after three days of apheresis alone [65].

如果使用胰島素治療的病患. 應每隔 12 小時測量TG.. 每小時測量血糖.  使用 5% 葡糖糖水加入 insulin. 直到TG 小於 500. 

●In patients treated with intravenous insulin, triglyceride levels should be monitored every 12 hours. Serum glucose should be measured every hour and the insulin/5 percent dextrose infusion should be adjusted accordingly. Intravenous insulin should be stopped when triglyceride levels are <500 mg/dL (5.6 mmol/L), which typically occurs within a few days.