Beyond triglyceride clearance: rethinking hypertriglyceridemia-associated acute pancreatitis in the apoC-III era

Hypertriglyceridemia-associated acute pancreatitis (HTG-AP) requires causal attribution rather than reliance on a single triglyceride (TG) threshold. Early TG measurement and assessment of competing or coexisting causes are essential because fasting, fluids, and correction of metabolic stress can produce substantial early TG decline. Severity should be determined by serial organ-function assessment using revised Atlanta and Modified Marshall criteria rather than TG concentration alone. Acute management should prioritize standard pancreatitis care, moderate crystalloid resuscitation, analgesia, early oral or enteral nutrition, and correction of genuine metabolic drivers. Intravenous insulin is appropriate for diabetic ketoacidosis, uncontrolled diabetes, marked hyperglycemia, or clinically important insulin deficiency, but current evidence does not support routine insulin solely for TG lowering in insulin-sufficient patients. Heparin should not be used for TG lowering. Therapeutic plasma exchange (TPE) produces rapid biochemical TG clearance, but randomized and adjusted observational evidence has not established improvement in organ failure, pancreatic necrosis, hospital stay, or mortality. TPE should therefore not be used as routine or rescue TG-lowering therapy; exceptional multidisciplinary deliberation may occur only in narrowly defined circumstances and should not be interpreted as an evidence-based indication or recommendation. After recovery, phenotype-directed assessment using fasting lipids, apolipoprotein B, evaluation of secondary drivers, and selective genetic testing can distinguish familial from multifactorial chylomicronemia and guide prevention. Hepatic apolipoprotein C-III (apoC-III) inhibition currently has the strongest randomized evidence for reducing pancreatitis events in relevant chylomicronemia populations. Management should prioritize prevention of organ injury during the acute episode and prevention of subsequent pancreatitis rather than the fastest possible TG decline.