hypertriglyceridemia jenny shu, im pgy-1 november 28, 2012
TRANSCRIPT
Hypertriglyceridemia
Jenny Shu, IM PGY-1November 28, 2012
Objectives
To outline an approach to patients with hypertriglyceridemia
To discuss primary and secondary causes of hypertriglyceridemia
To discuss the non-pharmacologic and pharmacologic therapies available for hypertriglyceridemia
Definition
Serum triglyceride (TG) concentration can be stratified in terms of population percentiles and/or coronary risk Normal — 1.7 mmol/L Borderline high — 1.7 to 2.2 mmol/L High — 2.3 to 5.6 mmol/L Very high — ≥5.7 mmol/L
Sources of plasma TG
Exogenous From dietary fat
After meal > 90% circulating TG originate in intestine, secreted in CMs
Endogenous From liver
During fasting, secreted by liver as VLDL predominate – hydrolyzed by LPL free FA
Lipid metabolism
High TG because of either: Increased production from liver and intestine
(upregulated synthetic and secretory pathways)
Decreased peripheral catabolism – reduced LPL activity
Why do we care?
Hypertriglyceridemia has implications for: Cardiovascular disease
Directly Indirectly
Pancreatitis Cerebrovascular disease
Incidence
Data from Genest JJ, McNamara JR, Ordovas JM, et al. J Am Coll Cardiol 1992; 19:792.
In US National Health and Nutrition Examination Surveys (NHANES) from 1999 to 2004
% adults with TG > 1.7mmol/L – 33%
TG > 2.3 mmol/L – 18%
TG > 5.7 mmol/L -1.7%
TG > 11.3 mmol/L – 0.4%
Types of hypertriglyceridemia Primary (inherited)
Familial chylomicronemia (type I) Primary mixed hyperlipidemia (type V) Familial hypertriglyceridemia (type IV) Familial combined hyperlipoproteinemia (type
IIB) Familial dysbetalipoproteinemia (type III)
Secondary (acquired) Medications or exogenous substances Other medical conditions
Primary Hypertriglyceridemia
Familial chylomicronemia (I) & primary mixed hyperlipidemia (V) Both associated with pathologic presence
of CMs after 12-14h period of fasting Clinical features include eruptive xanthomata,
lipidemia retinalis, HSM, focal neurological deficits (irritability), recurrent epigastric pain (pancreatitis risk)
Typically plasma TG > 10 mmol/L
Primary Hypertriglyceridemia
Familial chylomicronemia (I) vs primary mixed hyperlipidemia (V) Timing of onset Biochemically proven deficiencies in
LPL, apo CI activity or homozygous gene mutations
Secondary factors Greater elevation of total cholesterol
Clinical Manifestations
Eruptive cutaneous xanthoma – trunk, buttocks, extremities
Lipemia retinalis – usually TG > 35 mmol/L
Palmar crease xanthomas – Type III
Tuberous xanthomas – extensors, usually Type III
Yuan G et al. CMAJ 2007;176:1113-1120
When draw blood, you will see
Creamy supernatant when refrigerated overnight
(4 degrees C)
Yuan G et al. CMAJ 2007;176:1113-1120
Primary Hypertriglyceridemia Mixed hypertriglyceridemia
(Type IV) Isolated elevation VLDL (not as TG rich
as CMs), 5-10% population prevalence Likely polygenic Mod elevated plasma TG (3-10 mmol/L) Low levels HDL-C Increased risk CAD, obesity insulin
resistance, DM, htn, hyperuricemia
Primary Hypertriglyceridemia Familial dysbetalipoproteinemia (type III)
Increase in TG rich lipoprotein remnants – IDL or beta-VLDL that produce equimolar elevation plasma total cholesterol and TG
Population prevalence 1-2 in 20 000 Usually homozygotic for binding defective APOE E2
isoform – phenotypic expression often requires other RF such as T2DM, obesity, or hypothyroidism
Also with elevated LDL (interrupted processing VLDL) – diagnostic when high VLDL-C: TG ratio with E2/E2 homozygosity
Increased risk cardiovascular disease, often have tuberous/tuberoeruptive xanthomata on extensor surfaces
Primary Hypertriglyceridemia Familial combined
hyperlipoproteinemia (Type IIB) Increased VLDL and LDL, low HDL Autosomal dominant with variable
penetrance, 2-5% population prevalence At least one 1st degree relative with abn lipoprotein
profile Affected individuals usually obligate
heterozygosity for LPL or APO3 gene mutation, but unknown molecular basis in most cases, other genes implicated include USF1, APOA5, APOC3
Secondary Hypertriglyceridemia Other medical conditions
Renal disease Usually ass. With high LDL-C Nephrotic syn ass high apo B containing
lipoproteins such as VLDL Obesity/metabolic/DM
Excess adipose tissue – high TG, low HDL-C Part of metabolic syndrome
NASH High TG, low HDL-C are defining components Statin treatment may be more effective than
fibrates
Secondary Hypertriglyceridemia Other Medical conditions
Pregnancy – during T3, plasma TG can go up to 3x normal
Minimal clinical consequence Should not always assume due to pregnancy – can
get chylomicronemia (rare) complicated pancreatitis = serious health consequences for mother and fetus
Other Sedentary lifestyle Diet – positive energy intake balance and high fat/GI Paraproteinemias e.g hypergammaglobuliemia in
macroglobulinemia, yeloma, lymphoma, lymphocytic leukemias), autoimmm (SLE)
Secondary Hypertriglyceridemia Medications or Exogenous
Substances Medications
Steroids, estrogens (esp po), tamoxifen, anti-htn (non cardioselective BB, thiazides), isotretinoin, bile acid-binding resins, cyclophosphamide, antiretroviral regiemns (HAART), psychotropic (phenothiazines, 2nd gen anti psychotics)
Alcohol Due to high VLDL +/- chylomicronemia Can have normal TG because of adaptive increase in
lipolytic activity
Approach to Management IF TG > 10 – start FIBRATE right away
Then lifestyle, rule out secondary causes, dysglycemia
If TG 4.5 – 10, Lifestyle intervention, rule out secondary causes Address dysglycemia Fibrate, ezetimibe, niacin
If TG 2 – 4.5, Lifestyle intervention, rule out secondary causes Address dysglycemia If patient already on statin, can intensify statin
dose Or can try any of fibrate, niacin, fish oil, ezetimibeYuan G et al CMAJ 2007;176:1113-1120
Conservative Management
Non-pharmacological Conservative measures such as weight reduction,
diet modification, exercise Goal for dieting is to decrease wt overall intake of
energy/fat/refined carbs (high GI) Fat intake should be 10-15% total energy intake (15-
20 g/d) if severe hypertriglyceridemia Avoid alcohol Underlying cause – hypothyroid, renal disease etc. Better glycemic control of DM Omega-3 FA – component of Mediterranean diet
and fish oils Daily consumption 4g + restricted energy and
saturated fat intake can reduce TG by 20% Rarely effective when sole TG-lowering therapy
Pharmacologic agents Fibrates
Mainstay of treatment, generally well tolerated (rare hepatitis/myositis), other effects include reduction of LDL, increase HDL-C – activates PPAR-alpha to activate LPL action inducing lipolysis and elimination of TG rich particles
Statins Inhibit HMG-CoA reductae, not 1st line with TG >5 mmol/L as
monotherapy Safety profile appropriate combo with fibrate as FIELD showed no
rhabdomyolysis among more than 1000 patients taking combination statin + fenofibrate
Niacin (daily consumption up to 3g) Binds GPCR and inhibits adipose breakdown, decreases VLDL,
increases HDL, lowers TG up to 45%, start low & gradually increase Other lipid lowering medications
Ezetimibe – inhibits cholesterol absorption, safe in combo with fibrates
Emerging treatments
Efficacy of Various Agents Fibrates 10-50% ↓TG Ezetimibe 10-15% ↓TG Statins 7-30% ↓TG Niacin 20-50% ↓TG Omega-3 fatty acids 15-20% ↓TG
Evidence for Omega-3 Contain EPA and DHA – dose dependent TG lowering
effect through various mechanisms – decreased VLDL secretion, improved VLDL TG clearance
JELIS trial (Yokoyama et al Lancet 2007; 369; 1090-8) found 1.8g/d EPA supp + low dose statin decreased rate major coronary events compared statin monotherapy (? Related to TG since minimal reduction in levels (reduction 9% from baseline in EPA group vs. 4% in controls) p<0·0001
GISSI-P (Lancet 1999; 354, 447-455) showed 1g/d as 1 cap Omacor reduced all cause mortality and sudden death in patients with previous MI’s
Benefit on mortality? Recent JAMA systematic review and meta-analysis 2012
(Rizo et al) overall, omega-3 PUFA supplementation was not associated with a lower risk of all-cause mortality, cardiac death, sudden death, myocardial infarction, or stroke based on relative and absolute measures of association
Did not support that higher TG lowering dose was more protective than lower TG lowering dose
Fibrates Fenofibrate – most commonly
prescribed Lipidil EZ 145 mg od Lipidil (fenofibrate) supra 160 mg od Fenofibrate 200 mg od
Gemfibrozil (lopid) 600-1200 mg od Bezafibrate (bezalip) 400 mg od
Safety concern with fibrates Baseline and post-initiation
CK, creatinine, INR (if receiving anti-coagulants – potentiates actions) – risk myalgias, myopathy, rhabdomyolysis
If using in combination with statin, fenofibrate recommended (lower risk rhabdo)
Be aware of implications of renal dysfunction Up to 15-20% increase in Cr acceptable, but may
need to dose reduce Potential increased risk for cholelithiasis
(clofibrate), follow LFT’sDavidson MH et al Am J Cardiol 2007;99(6A):3C-18C
Evidence for fibrates
Meta-analysis looked at 6 RCT’s, showing fibrate Tx significantly reduced subsequent vascular event risk and effective in lowering TG levels FIELD ACCORD-Lipid
Lee M et al Atherosclerosis 2011;217:492-498
Meta-analysis: Fibrates & CVD
Trial (drug)population
% of patients
with diabetes
Primary endpoint:
entire cohort
(p value)
Lipid subgroup criterion
Analysis(p value)
HHS(gemfibrozil)4081 (100% male)
3 -34% (0.02) TG > 2.26 mmol/LLDL-C/HDL-C > 5.0
Post-hoc-71%
(<0.005)
VA-HIT(gemfibrozil)2531 (100% male)
25 -22% (0.006)
TG ≥ 1.69 mmol/L Post-hoc-27% (0.01)
BIP(bezafibrate)3090 (91% male)
10 -7.3% (0.26) TG ≥ 2.26 mmol/L Post-hoc-39.5% (0.02)
FIELD(fenofibrate)9795 (63% male)
100 -11% (0.16) TG ≥ 2.30 mmol/LHDL-C < 1.086
mmol/L
Post-hoc-27%
(0.005)
ACCORD(fenofibrate)5518 (69% male)
100 -8% (0.32) TG ≥ 2.30 mmol/LHDL-C ≤ 0.879
mmol/L
Prespecified-31% (0.06)
Evidence for fibrates – meta analysis
Lee M et al Atherosclerosis 2011;217:492-498
FIELD Studied effect of fenofibrate on cardiovascular
disease events in DM patients (not taking statin at entry)
Allocation to fenofibrate (200 mg daily) resulted in reductions relative to placebo in plasma total-cholesterol concentration of 11%, LDL-cholesterol level of 12%, and TG of 29%, and increases in levels of HDL cholesterol of 5% after 4 months of treatment.
However no statistically significant reduction in combined outcome of all-cause mortality and non fatal MI’s despite reducing TG’s
Did show reduction in non-fatal MI and coronary revascularization rate in fenofibrate arm, reduction microvascular complications of DM, reductions proteinuria and laser eye interventions FIELD Lancet 2005;366:1849-1861
FIELD
FIELD Lancet 2005;366:1849-1861
ACCORD-Lipid Whether combination therapy with a statin (simvastatin)
plus a fibrate (fenofibrate) vs. statin alone reduces cardiovascular risk in T2DM patients at high risk
Median plasma triglyceride levels decreased from 1.85 to 1.38 mmol/L in fenofibrate group and from 1.81 to 1.63 mmol/L in placebo group
Conclusion was that combo fenofibrate and simvastatin did not reduce the rate of fatal cardiovascular events, nonfatal myocardial infarction, or nonfatal stroke, as compared with simvastatin alone
However pre-specified subgroup with TG >11.3 mmol/L and HDL < 1.89mmol/L could benefit due to improvement of primary outcome (p = 0.057)
FDA May 2011- trial not designed for mixed dyslipidemia, inappropriate to infer combo therapy ineffective
ACCORD LIPID NEJM 2010;362:1563-1574
ACCORD-Lipid
ACCORD LIPID NEJM 2010;362:1563-1574
Conclusion Classify hypertriglyceridemia based on
severity – moderate RF for cardiovascular/CVS disease, severe RF for pancreatitis
When thinking about etiology, consider primary vs. secondary causes
Based on severity, consider non-pharmacological and pharmacological Tx and don’t forget about safety profile
Needs to be more high-powered RCT’s looking at combination therapy and cardiovascular outcomes
Discussion/Questions
Thanks for your attention.