Very Severe Hypertriglyceridemia (TGL ≥ 1000 mg/dL): Management - Adult - Inpatient/Ambulatory/Emergency Department Guideline Summary Target Population: Adult patients (age ≥ 18 years) with very severe hypertriglyceridemia (triglycerides ≥1000 mg/dL) Full Guideline: Very Severe Hypertriglyceridemia (TGL ≥ 1000 mg/dL): Management - Adult – Inpatient/Ambulatory/Emergency Department Patient has Hypertriglyceridemia (TG ≥ 1000 mg/dL) Does patient have symptoms? (i.e., abdominal pain, nausea/vomiting, vision changes, impaired cognition, paresthesias) Admit Patient and Treat • Address secondary causes • Start fenofibrate (160 mg) or micronized fenofibrate (200 mg) daily • Obtain diabetes management consultation if hyperglycemic • Start glycemic control (e.g., metformin, insulin infusion) if hyperglycemic • Patient should be NPO • Obtain nutrition consult for very-low fat diet YES Does patient have pancreatitis? YES Consider Plasmapheresis • Consult Pathology/Transfusion Service for plasmapheresis • Consult Interventional Radiology for line placement • Evaluate for Primary and Secondary Causes • Obtain Labs: Serum glucose, hemoglobin A1C, Creatinine, TSH, UA with protein/creatinine ratio Arrange Follow-up and Discharge Patient • Follow-up with PCP within 2 weeks • Follow-up with Preventive Cardiology in 6 weeks NO Treat and Arrange Follow-up • Address secondary causes • Start fenofibrate (160 mg) or micronized fenofibrate (200 mg) daily • Follow-up with PCP within 2 weeks • Follow up with Preventive Cardiology in 6 weeks NO Management of Very Severe Hypertriglyceridemia Primary and Secondary Causes of Hypertriglyceridemia Primary Causes • Familial combined hyperlipidemia • Lipoprotein lipase deficiency • Familial dysbetalipoproteinemia • Apolipoprotein CII deficiency • Apolipoprotein C-III excess • Familial chylomicronemia syndrome Secondary Causes • Untreated/poorly controlled diabetes mellitus • Obesity • High fat/high carbohydrate/high caloric diet • Excessive alcohol consumption • Hypothyroidism • Nephrotic syndrome • Pregnancy • Medications (see table below) Common drugs/medications that can raise triglycerides • −blockers • Glucocorticoids • Estrogens • Progestins • Tamoxifen • Androgenic steroids • Retinoids, isotretinoin • Thiazide/thiazide-type diuretics • Protease inhibitors • Loop diuretics • Tacrolimus • Cyclosporine • Atypical antipsychotics (e.g., clozapine, olanzapine) • Valproate • Alcohol Consideration for Plasmapheresis if ACE-I Usage ACE-I usage SIRS ≥ 2 SIRS = 0 or 1 No ACE-I taken in past 24 hours Favors performing plasmapheresis Consider plasmapheresis ACE-I taken within past 24 hours* Consider plasmapheresis with extra caution Favors deferring plasmapheresis * If plasmapheresis is performed within 24 hours of last ACE inhibitor dose, must be done in IMC or ICU setting only after multidisciplinary consultation and patient informed consent Effective 2/10/2021. Contact CCKM@uwhealth.org for previous versions. Copyright © 2021 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission Contact: CCKM@uwhealth.org Last Revised: 02/2021