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[Two of the authors respond:]
We appreciate the interest that the correspondents have shown in our review of hypertriglyceridemia.1 Our comment regarding the relative ineffectiveness of fish oil as monotherapy was provided in the context of the treatment of severe hypertriglyceridemia. We agree with Bruce Holub's comments regarding the efficacy of DHA and EPA for milder presentations of hypertriglyceridemia, and Table 2 of our article reflects this position. We also accept the potential efficacy of the combination of DHA and EPA with statin drugs in patients with combined hyperlipidemia. However, this combination awaits evaluation in larger prospective controlled studies.
Ifran Yavasoglu and colleagues and Georg Röggla and colleagues report dramatic improvements in severe hypertriglyceridemia associated with the use of plasma exchange and insulin and heparin administration, respectively. We also observed apparently dramatic biochemical improvement associated with heparin infusion.2 However, our clinical experience with patients who have serum triglyceride concentrations greater than 20 mmol/L, often accompanied by acute pancreatitis, is that admission to hospital with cessation of oral intake and appropriate intravenous fluid replacement (with or without insulin therapy depending on the presence of hyperglycemia) is typically followed by a rapid reduction in plasma triglyceride levels irrespective of other treatment modalities.
When oral food and fluids are withheld, a clinical rule of thumb is that triglyceride levels decay exponentially with a half-life of approximately 48 hours. This is comparable to the reductions observed by Yavasoglu and colleagues for plasma exchange and by Röggla and colleagues for a combined insulin and heparin regimen. Controlled, randomized studies, although logistically challenging, would be required to define the risk versus benefit to patients with severe hypertriglyceridemia of either plasma exchange or routine infusions of insulin or heparin. Until then, we stand by our position that these modalities should be used sparingly, if at all, in this situation.
Footnotes
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Competing interests: None declared.