高三酸甘油酯血症的診斷與治療指引新進展

Updated Guideline for the Diagnosis and Treatment of Hypertriglyceridemia

高三酸甘油酯血症是基層醫療重要課題。因高劑量二十碳五烯酸(eicosapentaenoic acid, EPA)藥物發展與文獻證據，近年各國際醫學組織及台灣相關醫學會都針對高三酸甘油酯血症處置指引有所更新。

高三酸甘油酯血症可分為原發性與次發性原因。原發性指與脂肪代謝相關的基因變異造成。次發性包含生活型態、臨床疾病與藥物等。

血中三酸甘油酯嚴重過高可能在皮膚表現黃色瘤，包含發疹性黃色瘤、手掌黃色瘤等，以及視網膜脂肪血症。特別重要的是，高三酸甘油酯血症亦是心血管疾病發生的獨立危險因子，也會增加急性胰臟炎發作的風險。

處置高三酸甘油酯血症分為非藥物與藥物治療。非藥物治療強調減少酒精攝取、低油併均衡飲食、規律運動與適當減重。藥物治療包括纖維酸衍生物(fibrate)、菸鹼酸(niacin)及高劑量EPA藥物。在REDUCE-IT臨床隨機分派試驗中，證實使用高劑量EPA組別，所有心血管事件發生顯著降低30%風險(p<0.01)，然須注意可能會提高心房顫動風險。

近年國際醫學組織在診治高三酸甘油酯血症指引中，雖有細節差異，但都強調先評估有無次發原因及生活習慣控制，再計算動脈硬化心血管疾病風險，若高風險或本身就有心血管疾病，必須先用史他汀(statin)類藥物改善低密度膽固醇(low-density lipoprotein cholesterol, LDL-C)到治療標準，若三酸甘油酯值仍高，高風險者可考慮使用高劑量EPA藥物。中華民國血脂及動脈硬化學會也預計在2022年提出台灣版降血脂初級預防指引，提及高三酸甘油酯血症的高風險族群，EPA藥物可考慮使用。建議健保署根據近年最新指引，調整關於降三酸甘油酯藥物的給付規定。

 

Hypertriglyceridemia is an important issue of primary health care. Because of the development of new medication, high-dose eicosapentaenoic acid (EPA) and its clinical evidence, in recent years, several medical organizations including American College of Cardiology (ACC), American Association of Clinical Endocrinology (AACE) proposed updated guidelines for the evaluation and management of hypertriglyceridemia.

The causes of hypertriglyceridemia can be ascribed as primary or secondary. Primary causes are genetic abnormality. Secondary causes include lifestyle factors, diseases and medications related.

Xanthomatosis including eruptive xanthomas and palmar xanthoma and lipemia retinalis can be seen in severe hypertriglyceridemia. Most importantly, hypertriglyceridemia is an independent risk factor of cardiovascular disease and also increases the risk of acute pancreatitis attack.

Both non-pharmacological method and medications can be used in the management of hypertriglyceridemia. The non-pharmacological method includes limited alcohol consumption, low fat and balanced diet, regular exercise and adequate weight control. Medications such as fibrate, niacin and high-dose EPA can lower serum triglyceride level. In REDUCE-IT randomized control trial, the high-dose EPA group had 25% lower major adverse cardiovascular events compared to the placebo group (p<0.0001). However, the slightly increasing risk of atrial fibrillation should be kept in mind.

Recent guidelines, including AHA, AACE, as well as Taiwan medical associations, all throw a strong light on searching the secondary causes of hypertriglyceridemia and doing non-pharmacological method first, and then treat hypertriglyceridemia if cardiovascular disease (ASCVD) risk is high. In higher risk patients, the statin-based therapy to reach low-density lipoprotein cholesterol (LDL-C) treatment goal should be applied at first. If LDL-C is well controlled but hypertriglyceridemia persists, high-dose EPA can be considered to use in high-risk group. Taiwan society of lipid and atherosclerosis will also proposed updated Taiwan lipid guideline for primary prevention in 2022, which mentioned in high-risk patient with hypertriglyceridemia, EPA medication can be considered. It is suggested that Taiwan National Health Insurance Administration ought to adjust the reimbursement criteria for the medications of hypertriglyceridemia in accordance with the recent updated guidelines.