Case of familial hyperlipoproteinemia type III hypertriglyceridemia induced acute pancreatitis: Role for outpatient apheresis maintenance therapy

Table 1 Summary of hypertriglyceridemic pancreatitis management strategies

Management strategy	Description	Indication	Outcomes	Case report/Ref.
Diet restriction	Absolute restriction of fat intake	HTG, Primary prevention	Effective when combined with lipid lowering agents[15]	Tsuang et al[15], 2009
Lipid lowering agents	Fibrates (gemfibrozil 600 mg twice daily), niacin, N-3 fatty acids, statins	First line in HTG	Triglyceride level lowered about 60% by fibrates, about 50% by niacin, about 45% by omega-3 fatty acids[15]	Tsuang et al[15], 2009
		Adjuvant therapy in HTGP
Apheresis	Therapeutic Plasma Exchange which is removal of plasma and replacement with colloid solution (albumin, plasma). Citrate is used as an anticoagulant. Goal is TGH < 500	HTGP without contraindication to Apheresis such as inability to obtain central access or hemodynamic instability	Appears to be effective based on multiple case reports and case series. about 41% decrease in HTG levels. Apheresis within 48 h associated with better outcomes[16]	Furuya et al[16], 2002
Insulin	Intravenous regular insulin drip (0.1 to 0.3 units/kg/h). Goal is TGH < 500. Used alone or in combination with apheresis and/or heparin	Apheresis unavailable unable to tolerate apheresis	Intravenous insulin is more effective than subcutaneous[17]	Berger et al[17], 2001
		hyperglycemia > 500	Effective in lowering triglyceride levels
Heparin	Combined with insulin. Subcutaneous heparin 500 units BID in 2 case reports	Controversial in HTGP	Controversial. Associated with increased mortality when compared to citrate (both combined with apheresis)[18].	Gubensek et al[18], 2014
Periodic apheresis	Described in 2 patients as monthly apheresis in 1996	Recurrence prevention especially in noncompliant patients	Reported success in one case report (2 patients in 1996)[21].	Piolot et al[21], 1996

HTGP: Hypertriglyceridemic pancreatitis; HTG: Hypertriglyceridemia; BID: Bis in die; TGH: Triacylglycerol hadrolase.