Managing a dramatic rise in triglycerides

[SpongeBob DoctorPants]

I have an 11 year old male patient, for whom I have checked glucose and lipids due to being on an antipsychotic (Seroquel) long term. One year ago, his labs were normal. Now, the labs are mostly normal still, with the exception that his triglyceride level has risen dramatically from 68 one year ago, to 226 currently. There has been no significant change in weight; he weighed 30.6 kg (BMI 16.0) one year ago, compared to 31.5 kg (BMI 15.7) currently.

The lab was drawn at a different facility this time, but I don't know if that alone would account for the significant difference. The dose of Seroquel has remained the same over the past year (50 mg qam and 100 mg qhs), and is actually at a lower dose than he used to take prior to one year ago, so I wouldn't necessarily suspect that Seroquel has caused this. His other current medications include Adderall and acyclovir.

I've read that foods high in sugar can rapidly raise triglyceride levels, and Halloween was just a week ago, so I had a thought that maybe he ate tons of candy over the few days preceding his lab draw, but I doubt that this would lead to such a dramatic rise that quickly.

I am considering having the lab repeated to verify its accuracy. Any other ideas?

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[deleted87716]

Theat’s still not really all that elevated. He may well have not been fasting. I wouldn’t do anything at this point except consider repeating them in 6 to 12 months.

 

[VA Hopeful Dr]

Theat’s still not really all that elevated. He may well have not been fasting. I wouldn’t do anything at this point except consider repeating them in 6 to 12 months.

Yep.

OP bear in mind that outside of diabetics and levels high enough to make you worry about pancreatitis, triglycerides really aren't that important.

 

[smq123]

I've read that foods high in sugar can rapidly raise triglyceride levels, and Halloween was just a week ago, so I had a thought that maybe he ate tons of candy over the few days preceding his lab draw, but I doubt that this would lead to such a dramatic rise that quickly.

It very well might have. Depends on how hard he was hitting the candy.

Like BD and VA, I'd repeat it in a few months, and just talk to him about healthy diet and exercise, etc.

 

[SpongeBob DoctorPants]

Thanks everyone, I appreciate the helpful responses.

 

[PlutoBoy]

Yep.

OP bear in mind that outside of diabetics and levels high enough to make you worry about pancreatitis, triglycerides really aren't that important.

This is an outdated understanding of hypertriglyceridemia. There has been renewed interest in this topic as it becomes more evident that high TGs are associated with CV events. I think that the new guidelines will probably reflect this. The European guidelines already do.

 

[deleted87716]

This is an outdated understanding of hypertriglyceridemia. There has been renewed interest in this topic as it becomes more evident that high TGs are associated with CV events. I think that the new guidelines will probably reflect this. The European guidelines already do.

Elevated fasting trigs may be associated with increased levels of atherogenic lipoproteins. However, this wouldn't likely be clinically significant in an 11-y/o patient.

I used to measure and treat things like LDL-p all the time (based on NLA guidelines) until most insurance plans stopped covering advanced lipid testing. Most patients don't want to pay out-of-pocket for it, and it takes too long to have those conversations. I'm pretty much just following the ACC/AHA guidelines now. Lots of people aren't even doing that. I saw a new patient yesterday who switched doctors because he was told to take Lipitor over the phone without much discussion as to the rationale. He had an unremarkable FLP except for an LDL-c of 141, and no other risk factors. His 10-yr. ASCVD risk according to the ACC/AHA calculator was <5%. So, no need for Lipitor.

 

[deleted87716]

Tangentially, I'm digging the Latin custom title.

 

[VA Hopeful Dr]

Elevated fasting trigs may be associated with increased levels of atherogenic lipoproteins. However, this wouldn't likely be clinically significant in an 11-y/o patient.

I used to measure and treat things like LDL-p all the time (based on NLA guidelines) until most insurance plans stopped covering advanced lipid testing. Most patients don't want to pay out-of-pocket for it, and it takes too long to have those conversations. I'm pretty much just following the ACC/AHA guidelines now. Lots of people aren't even doing that. I saw a new patient yesterday who switched doctors because he was told to take Lipitor over the phone without much discussion as to the rationale. He had an unremarkable FLP except for an LDL-c of 141, and no other risk factors. His 10-yr. ASCVD risk according to the ACC/AHA calculator was <5%. So, no need for Lipitor.

I tend to follow the ACC/AHA as well... unless you're over 30, male, and your LDL is over 160 (same thing with women but age 40). Unless those guys have HDLs in the 60s, they're getting a statin. Not especially evidenced based, but I just can't ignore LDLs that high. Plus their 10 year risk is pretty low but their lifetime risk is going to be pretty high.

 

[PlutoBoy]

I tend to follow the ACC/AHA as well... unless you're over 30, male, and your LDL is over 160 (same thing with women but age 40). Unless those guys have HDLs in the 60s, they're getting a statin. Not especially evidenced based, but I just can't ignore LDLs that high. Plus their 10 year risk is pretty low but their lifetime risk is going to be pretty high.

The absolute risk reduction in such a scenario is likely to be minimal and you are exposing a young person to decades of statin therapy, expense, and side effects for a negligible benefit.

In other words, if your patient’s risk is 1% to begin with pursuing to reduce his relative risk by another 0.2% over the course of ten years of therapy (which is what we could reasonably expect from statin therapy) is not reasonable.

Stick to the guidelines.