Basic information of the case
The patient is a 56-year-old male.
Chief complaint: Triglycerides (TG) were found to be elevated and poorly controlled for 30 years.
History of present illness: The patient was found to have elevated TG 30 years ago, and was tested for lipidemia several times, and usually took "fenofibrate" to lower TG. After treatment, TG was not well controlled, and multiple reexaminations still showed lipid status. More than 20 years ago, he began to have recurrent abdominal pain, and was hospitalized many times to diagnose "pancreatitis", and the TG was at a severely elevated level at each episode. In the past 20 years, he has been hospitalized in other hospitals for "pancreatitis" more than 30 times, and has been admitted to the intensive care unit three times, all of which have been discharged after treatment. Usually continue to take "fenofibrate" treatment. Half a month ago, the patient was admitted to the outpatient clinic of our hospital for further diagnosis and treatment, and was admitted to the Department of Hepatobiliary Surgery for "pancreatitis". During hospitalization, he was diagnosed with severe hypertriglyceridemic acute pancreatitis (HTG-AP) and diabetic ketoacidosis, and his condition improved and he was discharged after treatment with "fenofibrate and insulin". After being discharged from the hospital, he regularly took "fenofibrate" and oral hypoglycemic therapy in the outpatient clinic, and the TG was significantly increased in the outpatient clinic, so he went to the Department of Cardiovascular Medicine. At the time of presentation, his mental state was acceptable, and he did not complain of significant discomfort.
Anamnesis: He has a history of recurrent "pancreatitis" for more than 20 years, and has reported more than 30 hospitalizations, including 3 hospitalizations in the intensive care unit, and the specific treatment is unknown. He has a history of diabetes for more than 10 years, usually takes "gliclazide sustained-release tablets" for treatment, and reports that his fasting blood sugar is maintained at 6-8mmol/L most of the time. Denial of history of coronary heart disease, hypertension, thyroid dysfunction, chronic kidney disease, etc., and no history of other diseases and related medications.
Personal history: long-term light diet, less exercise, no tobacco and alcohol intake.
Family history: my brother has a similar history of hypertriglyceridemia.
Outpatient examination: blood pressure 100/70 mmHg, chronic appearance, thin build, no significant cardiopulmonary abnormalities. There is no tenderness or rebound tenderness in the abdomen, and bowel sounds are normal.
Outpatient diagnosis: hypertriglyceridemia; HTG-AP； Diabetes mellitus (to be classified).
Recent Tests and Treatment Options:
- On the basis of "fenofibrate 0.2g bid", combined with "omega-3 fatty acid ethyl ester 90 soft capsule 2g bid" to achieve the purpose of further lipid-lowering therapy.
- After treatment with the combination of "fenofibrate 0.2g bid + omega-3 fatty acid ethyl ester 90 softgel 2g bid", the patient's serum total cholesterol (TC) gradually decreased to normal level, and TG also decreased significantly to normal level.
Medication analysis
The presence of a definite severe hypertriglyceridemia in this patient, with a similar condition in his brother, does not exclude the possibility of hereditary dyslipidemia, such as an autosomal hereditary lipoprotein lipase (LPL) deficiency disorder. For this patient, the greatest harm is the already recurrent episodes of HTG-AP. In recent years, domestic research data have shown that hyperlipidemia has surpassed alcohol as the second most common cause of acute pancreatitis (AP), which is closely related to significantly elevated serum TG1. Serum TG level ≥ 11.3 mmol/L is the most important feature of HTG-AP pathogenesis1. The Expert Consensus on the Diagnosis and Treatment of Hypertriglyceridemia Acute Pancreatitis (hereinafter referred to as the "Expert Consensus") published in 2021 pointed out that1, HTG-AP is easily misdiagnosed in the early stage due to the characteristics of "hidden triggers and insignificant increase in amylase level", and HTG-AP needs to be paid enough attention due to its "younger onset, many comorbidities", rapid disease progression, and "severe" tendency, which is easy to cause short-term and long-term harm to patients, families, and society.
In this patient, strict control of markedly elevated hypertriglyceridemia is a top priority for the prevention of HTG-AP. The "Expert Consensus" recommends1, patients with mild HTG-AP who are stable should take oral lipid-lowering drugs as soon as possible, including fibrate lipid-lowering drugs, statins, niacin, omega-3 fatty acids, etc., and pointed out that omega-3 fatty acids can not only inhibit the production of TG in the liver, but also enhance the lipid-lowering effect by reducing the levels of low-density lipoprotein cholesterol (LDL-C) and chyle granules. Both the 2023 Chinese Guidelines for the Management of Blood Lipids 2 and the 2024 Chinese Guidelines for the Management of Blood Lipids (Basic Edition)3 clearly recommend that when the TG is ≥ 5.6 mmol, fibrates, high-purity medical-grade omega-3 fatty acids or niacin should be treated immediately to reduce the risk of pancreatitis. In this case, the patient had a TG level of 21.53 mmol/L before hospitalization, and AP was present during hospitalization, so he was treated with fenofibrate. According to the results of the re-examination, the efficacy of fenofibrate was significant, and the TG level decreased from 21.53 mmol/L to 15.92 mmol/L, but the TG level was still as high as 15.92 mmol/L, which was higher than the AP threshold level of 5.65 mmol, and even higher than the danger level of 11.3 mmol. The patient's history of multiple hospitalizations largely excludes the possibility of elevated TG due to secondary factors. Therefore, considering the combination drug regimen given to the patient, and the comprehensive guideline recommendation, as well as the characteristics of low LDL-C and large niacin side effects, the combination lipid-lowering regimen of fenofibrate + omega-3 fatty acid ethyl ester 90 soft capsule was preferred, and the TG level of the patient continued to decrease to 2.21mmol/L after the combination of drugs, which proved that this regimen did bring greater benefits to the patients.
brief summary
The patient had a history of hypertriglyceridemia for more than 30 years, with poor long-term control, and began to have recurrent HTG-AP more than 20 years ago, so strict control of TG level became the focus of treatment for this patient. According to the consensus recommendations of multiple guidelines, on the basis of the strict good dietary habits and the use of fenofibrate, the combination of omega-3 fatty acid ethyl ester 90 soft capsules aims to reduce TG levels and prevent the occurrence of AP. At present, this patient continues to be treated with fenofibrate + omega-3 fatty acid ethyl ester 90 soft capsules combined with lipid-lowering therapy, and continues to strictly engage in lifestyle intervention and regular outpatient follow-up.
Attending Physician Wen
- Doctor of Medicine, Deputy Chief Physician, Master's Supervisor
- He is a member of the Cardiovascular and Cerebrovascular Chronic Disease Management Professional Committee of Guangdong Geriatric Health Care Association, and a member of the Metabolic Cardiovascular Disease Group of the Cardiovascular Disease Branch of Guangdong Medical Association
- He graduated from Sun Yat-sen University with a bachelor's degree in 2005 and obtained a doctorate degree in cardiovascular medicine from Sun Yat-sen University in 2013
- He has been engaged in the front line of clinical medical education and research for a long time, and has rich clinical practice experience in the diagnosis and treatment of cardiovascular diseases such as coronary heart disease, heart failure, arrhythmia, hypertension, cardiomyopathy, heart valve disease, syncope, tumor and cardiovascular disease
- He has presided over a provincial fund project, participated in a number of national and provincial scientific research projects, and won the Ministry of Education's Doctoral Academic Newcomer Award, Sun Yat-sen University's Doctoral Innovative Talent Training Funding Project, and the National Doctoral Scholarship
- So far, he has published more than 20 academic papers related to cardiovascular diseases, including more than 10 SCI papers as the first author
Bibliography:
1. Consensus Expert Group on Emergency Diagnosis and Treatment of Hypertriglyceridemia Acute Pancreatitis. Expert consensus on the diagnosis and treatment of hypertriglyceridemia acute pancreatitis. Chinese Journal of Emergency Medicine, 2021, 30(8) : 937-947.
2. Joint Expert Committee on the Revision of Chinese Guidelines for the Management of Blood Lipids. Guidelines for the management of blood lipids in China (2023). Chinese Journal of Circulation, 2023; 38(3): 237-271.
3. Joint Expert Committee on the Revision of Chinese Guidelines for the Management of Blood Lipids. Guidelines for the management of blood lipids in China (Grassroots Edition, 2024). Chinese Journal of Cardiovascular Diseases, 52: Online Pre-publication.
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