Hypertriglyceridemia in adults: Management

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節錄

根據 TG 水平進行額外治療一般方法之外的其他治療基於 TG 水平以及既往胰腺炎病史。出於管理目的，我們根據以下標準對空腹 TG 水平進行分類（從 mg/dL 轉換為 mmol/L，除以 88.5）：

●正常 – <150 mg/dL (<1.7 mmol/L)

●中度高甘油三酯血症 – 150 至 499 mg/dL（1.7 至 5.6 mmol/L）

●中度至重度高甘油三酯血症 – 500 至 999 mg/dL（5.65 至 11.3 mmol/L）

●嚴重高甘油三酯血症 – ≥1000 mg/dL (≥11.3 mmol/L)





高甘油三酯血症的更嚴格定義是空腹TG 水平>200 mg/dL，且不伴隨LDL-C 升高（無論有或沒有他汀類藥物治療），因為有限的證據表明貝特類藥物和海洋omega 脂肪酸在這種情況下對心血管有益。這是基於隨機對照試驗中血漿 TG 和 TG/HDL-C 比率的亞組分析，其中貝特類和 omega-3 脂肪酸（特別是 二十碳五烯酸乙酯）可能對心血管疾病的風險產生一些有益的影響 [ 9,10 ] 。相反，對於TG 水平為150 至200 mg/dL 且LDL-C 升高的患者，中至高劑量他汀類藥物治療可以治療LDL-C 升高，並且通常將TG 水平降低至正常水平（<150 mg/ dL）。 dL 或 1.7 mmol/L）。

監測治療

TG 水平監測的頻率取決於高甘​​油三酯血症的嚴重程度。

●對於接受嚴格膳食脂肪限制（每天<5%膳食脂肪）治療的嚴重高甘油三酯血症患者，我們經常（例如每三天）測量TG水平，以指導立即開始使用降TG藥物。



●對於中度或中度至重度高甘油三酯血症的患者，我們通常在開始或改變藥物治療後六至八週檢查 TG 水平。



藥物治療和生活方式改變降低 TG 水平的速度和效果各不相同（表 1）：

●當 TG 水平≥500 至 1000 mg/dL（5.6 至 11.3 mmol/L）時，膳食脂肪 <5% 的空腹 TG 預計每天減少 25% [14 ]。



●海洋 omega-3 脂肪酸療法可在兩週內看到大部分 TG 降低。(參見 下文‘對血脂水平的影響’ )



●貝特類藥物最早在治療兩週後就會出現反應，六到八週內發揮最大作用[ 15-17 ]。



●對菸酸（菸酸）的大部分反應 會在兩週內出現。


Hypertriglyceridemia in adults: Management

ADDITIONAL THERAPY BASED UPON TG LEVELAdditional therapy beyond the general approach is based upon the TG level as well as history of prior pancreatitis. For purposes of management, we classify fasting TG levels according to the following criteria (to convert from mg/dL to mmol/L, divide by 88.5):

●Normal – <150 mg/dL (<1.7 mmol/L)

●Moderate hypertriglyceridemia – 150 to 499 mg/dL (1.7 to 5.6 mmol/L)

●Moderate to severe hypertriglyceridemia – 500 to 999 mg/dL (5.65 to 11.3 mmol/L)

●Severe hypertriglyceridemia – ≥1000 mg/dL (≥11.3 mmol/L)



A more stringent definition for hypertriglyceridemia is a fasting TG level >200 mg/dL without an accompanying elevation in LDL-C (with or without statin therapy), as limited evidence suggests cardiovascular benefit of fibrates and marine omega fatty acids in this setting. This is based upon subgroup analyses of plasma TG and TG/HDL-C ratios in randomized controlled trials, in which fibrates and omega-3 fatty acids (particularly icosapent ethyl) may have some beneficial effects on risk of cardiovascular disease [9,10]. In contrast, for patients with TG levels of 150 to 200 mg/dL and elevated LDL-C, treatment with moderate- to high-dose statin treats the LDL-C elevation and generally lowers the TG levels to normal levels (<150 mg/dL or 1.7 mmol/L).

MONITORING THERAPY

The frequency of TG level monitoring depends upon the severity of hypertriglyceridemia.

●For patients with severe hypertriglyceridemia treated with stringent dietary fat restriction (<5 percent dietary fat per day), we measure TG levels frequently (eg, every three days) to guide prompt initiation of TG-lowering drugs.



●For patients with moderate or moderate to severe hypertriglyceridemia, we typically check TG levels six to eight weeks after starting or altering drug therapy.



Pharmacologic therapies and lifestyle modifications vary in how quickly and effectively they reduce TG levels (table 1):

●With TG levels ≥500 to 1000 mg/dL (5.6 to 11.3 mmol/L), the expected reduction in fasting TG with <5 percent dietary fat is 25 percent per day [14].



●The majority of TG reduction with marine omega-3 fatty acid therapy is seen in two weeks. (See 'Effects on lipid levels' below.)



●A response to fibrates is seen as early as two weeks into therapy, with a maximal effect in six to eight weeks [15-17].



●The majority of the response to niacin (nicotinic acid) is seen in two weeks.