New Physician Guidelines for High Triglyceride Detection and Treatment: Important health indicator

James Meschino DC, MS, ROHP

We hear a lot of discussion these days about high cholesterol and high blood sugar (glucose) levels, and their deleterious effects on our health with respect to heart disease, stroke, other vascular diseases, diabetes and its complications, and more recently Alzheimer’s disease. To some degree high triglycerides are not as popular a topic in the health and disease discussion, yet its importance ranks right up there with cholesterol and blood sugar.

Evidence shows that people with severe and very severe hypertriglyceridemia (high triglycerides) are at increased risk for pancreatitis, whereas mild or moderate hypertriglyceridemia may be a risk factor for cardiovascular disease. For this reason the new clinical-practice guidelines from the Endocrine Society recommends that all adults should be screened for high triglyceride levels once every five years.The new guidelines were published in the September 2012 issue of the Journal of Clinical Endocrinology and Metabolism.

The Danger of High Triglycerides
High triglcyerides are known to trigger pancreatitis, which is a very serious disorder that requires hospitalization during an attack.Pancreatitis is inflammation of the pancreas. It occurs when pancreatic enzymes (especially trypsin) that normally digest food, are activated in the pancreas. It may be acute – beginning suddenly and lasting a few days, or chronic – occurring over many years. Acute pancreatitis has a high mortality rate. Prognosis is highly determined by certain objective tests performed in the hospital. Doctors often use the mnemonic “PANCREAS” to assemble the clinical picture and prognosis in a patient presenting with a potential case of pancreatitis.“PANCREAS” and the pancreatitis incriminating readings associated with it stand for:

• P02 Oxygen< 60mmHg or 7.9kPa
• Age > 55
• Neutrophilia White blood cells> 15
• Calcium< 2 mmol/L
• Renal Urea> 16 mmol/L
• Enzymes Lactate dehydrogenase (LDH) > 600iu/L Aspartate transaminase (AST) > 200iu/L
• Albumin< 32g/L
• Sugar Glucose> 10 mmol/L

Symptoms of Pancreatitis
The most common symptoms of pancreatitis are severe upper abdominal pain radiating to the back, nausea, and vomiting that is made worse by eating. Damage to the pancreas may result in internal bleeding.Fever or jaundice may be present. In both acute and chronic forms of pancreatitis unexplained weight loss may occur from a lack of pancreatic enzymes hindering digestion.

Chronic pancreatitis can lead to diabetes and is associated with an increased risk of pancreatic cancer and thus, its management should be a priority once identified.

Causes of Pancreatitis
Eighty percent of pancreatitis cases are linked to alcohol and the presence of gallstones. Gallstones are the single most common cause of acute pancreatitis whereas alcohol is the single most common cause of chronic pancreatitis. Alcohol also increased triglyceride levels in the blood. Some commonly used drugs that increase the risk of pancreatitis include corticosteroid drugs like prednisone, diuretic drugs used to lower blood pressure, statin drugs used to lower cholesterol, and estrogen used in hormone replacement therapy. Pancreatic duct stones are also an infrequent cause of pancreatitis that can be seen on an ultrasound.

New Recommendations for Triglyceride Screening and Management of High Triglycerides
What stands out in the new guidelines is the importance of following a low fat, low glycemic diet, the inclusion of endurance exercise, the use of omega-3 fat supplements, reducing or abstaining from alcohol consumption, and management of obesity, in the management of primary hypertriglyceridemia. The same factors are also important in the prevention of high triglycerides. The management of secondary hypertriglcyeridemia, which implies that high triglycerides are a result of a problem with an endocrine (hormone-producing) gland(s), or a side effect of a medication(s), requires identification and focus on the underlying primary cause in these cases.

The new 2012 guidelines for physicians to follow with respect to high triglyceride screening and management include:

• The diagnosis of hypertriglyceridemia be made on fasting triglyceride levels and not nonfasting levels.
• Individuals with high fasting triglyceride levels be evaluated for secondary causes of hyperlipidemia, including endocrine conditions and medications, and that treatment be focused on secondary causes.
• Patients with primary hypertriglyceridemia be screened for other cardiovascular risk factors.
• Patients with primary hypertriglyceridemia be evaluated for a family history of dyslipidemia and cardiovascular disease in order to assess future cardiovascular risk.
• Obese and overweight patients with mild to moderate hypertriglyceridemia be treated with lifestyle therapy, including dietary counseling, and physical-activity programs to achieve weight reduction.
• Dietary fat and simple-carbohydrate consumption be reduced in combination with drug therapy to lower the risk of pancreatitis for patients with severe and very severe hypertriglyceridemia.
• The treatment goal for patients with mild hypertriglyceridemia be a non–HDL-cholesterol level in agreement with the National Cholesterol Education Panel Adult Treatment Panel (NCEP ATP III) guidelines.
• Fibrates be used as a first-line drug to reduce triglycerides in patients at risk of triglyceride-induced pancreatitis.
• Fibrates, niacin, or omega-3 fatty acids be used alone or in combination with statins in patients with moderate to severe hypertriglyceridemia.
• And finally, statins not be used as monotherapy in patients with severe or very severe hypertriglyceridemia, although statins can be used to modify the risk of cardiovascular disease.

Triglyceride Blood Levels: What’s your score?
The ideal blood level of triglycerides for longevity and disease prevention is at or below 132 mg/dl or 1.5mmol/L.

In 2001, the National Cholesterol Education Program (NCEP) released recommendations on triglyceride levels that should determine whether hypertriglyceridemia medical treatment is required or not:

• Normal: less than 150 mg/dL
• Borderline: 150-199 mg/dL
• High: 200–499 mg/dL
• Very high or severe: higher than 500 mg/dL (2)

The next time you have a physical exam ask your doctor what your fasting triglyceride level is, and compare it to the values and ranking system above. To convert mg/dL to mmol/L, divide the value in mg/dL by 88.57.

References:

1 Berglund L, Brunzell JD, Goldberg AC, et al. Evaluation and treatment of hypertriglyceridemia: an Endocrine Society clinical practice guideline. J ClinEndocrinolMetab 2012; 97:2969.
2. http://www.diet.com/g/hypertriglyceridemia