A 22-year-old man comes to the emergency department with abdominal pain and vomiting. His symptoms began acutely 24 hours ago with nausea and decreased appetite. His medical history is unremarkable. The patient drinks 3-4 beers a week and does not use tobacco or illicit drugs. BMI is 37 kg/m². Physical examination is notable for moderate epigastric tenderness with decreased bowel sounds but no rebound tenderness, guarding, or abdominal rigidity. Fasting laboratory studies show a serum triglyceride concentration of 1,500 mg/dL (normal:

Question

A 22-year-old man comes to the emergency department with abdominal pain and vomiting. His symptoms began acutely 24 hours ago with nausea and decreased appetite. His medical history is unremarkable. The patient drinks 3-4 beers a week and does not use tobacco or illicit drugs. BMI is 37 kg/m². Physical examination is notable for moderate epigastric tenderness with decreased bowel sounds but no rebound tenderness, guarding, or abdominal rigidity. Fasting laboratory studies show a serum triglyceride concentration of 1,500 mg/dL (normal: <200 mg/dL). Once the patient has been medically stabilized, which of the following medications would be most helpful in preventing recurrences of his condition?

Quizplus · Accepted Answer

11ec160b_3ba8_eb9a_9249_dffdf1dbb930_MD0001_00 This patient most likely has acute pancreatitis due to severe hypertriglyceridemia. Small quantities of pancreatic lipase normally leak into the pancreatic capillaries, where they can metabolize triglycerides to free fatty acids, which have toxic and inflammatory effects on the pancreas. The risk of pancreatitis rises with increasing triglyceride levels and is most significant when triglycerides are severely elevated (>1,000 mg/dL). Triglycerides loosely reflect caloric balance; a calorie-restricted diet with increased exercise and reduced alcohol intake can provide a rapid and significant drop in triglyceride levels. Lipid-lowering medications are also indicated for patients with moderate to severe hypertriglyceridemia. Fibrates (eg, fenofibrate, gemfibrozil) work by activating peroxisome proliferator-activated receptor-alpha (PPAR-α), which increases the synthesis of lipoprotein lipase. (Choice A) Although statins (eg, atorvastatin) are the preferred lipid-lowering agents for the prevention of cardiovascular disease, they only modestly lower triglyceride levels and would be less effective than fibrates for preventing recurrent pancreatitis due to hypertriglyceridemia. (Choices B and C) Bile acid-binding resins (eg, cholestyramine) work by binding bile acids in the gastrointestinal tract, subsequently interfering with enterohepatic bile acid circulation. Ezetimibe selectively inhibits intestinal cholesterol absorption. These medications are used primarily for the treatment of hypercholesterolemia. (Choice E) Niacin decreases hepatic production of VLDLs and reduces triglyceride release from adipose tissue. It has a weaker effect in lowering triglycerides than fibrates and is associated with significant side effects, especially flushing. (Choice F) Fish oil supplements containing omega-3 fatty acids lower triglyceride levels by decreasing the production of VLDLs. Fish oils decrease serum triglycerides to a lesser degree than fibrates but may be added to fibrates in patients whose triglyceride levels are not adequately controlled with a fibrate alone. Educational objective: In patients with severe hypertriglyceridemia, pancreatic lipases can cause toxic levels of free fatty acids to be released within the pancreatic tissue, leading to acute pancreatitis. Fibrates (eg, fenofibrate) are the most effective agents for the treatment of hypertriglyceridemia. __________ References: Optimal pharmacologic approach to patients with hypertriglyceridemia and low high-density lipoprotein-cholesterol: randomized comparison of fenofibrate 160 mg and niacin 1500 mg. (http://www.ncbi.nlm.nih.gov/pubmed/20855072) Familial dyslipidaemias: an overview of genetics, pathophysiology and management. (http://www.ncbi.nlm.nih.gov/pubmed/17100406) Role of prescription omega-3 fatty acids in the treatment of hypertriglyceridemia. (http://www.ncbi.nlm.nih.gov/pubmed/17461707)

A 22-Year-Old Man Comes to the Emergency Department with Abdominal