We are excited to see so many of you join our FMEP courses. Several of you have requested we continue to post more practice SAMPs, so here you go!

SAMP

Eric Johnson is a 44-year-old man who presents to the local emergency department with severe epigastric pain. The pain has started to radiate to his back. He has had nausea and 3 episodes of vomiting. His BMI is 40. He has poorly controlled type 2 diabetes. He has hypothyroidism and hypertension. He is trying to lose weight and was advised by his gym coach to start a “carnivore diet” where he consumes mostly red meat, butter, eggs, and bacon. On examination, he appears uncomfortable. BP is 136/92, HR 86. His abdomen is soft, but tender on palpation in the epigastric area. His cardiovascular and respiratory examinations are unremarkable.

• Lipase: markedly elevated
• Triglycerides are elevated at 18.6 mmol/L
• HbA1c: 9.1%
• TSH is elevated at 8.

(10 points)

1. List two contributing causes of this patient’s severe hypertriglyceridemia. (2 points)

   Answer:
   Insulin resistance/poorly controlled diabetes
   Obesity
   Hypothyroidism
   High saturated fat dietary intake
   Excess caloric intake

2. What are the next appropriate management steps for hypertriglyceridemia-induced pancreatitis? (3 points)

   Answer:
   ABCs
   Supportive pancreatitis management (IV fluids, analgesia)
   Bowel rest/NPO initially
   Elimination of dietary fats
   Treat uncontrolled diabetes (consider insulin infusion if hyperglycemic)
   Consider plasmapheresis in severe or refractory cases
   Monitor triglyceride levels serially

3. What are three appropriate chronic management strategies after stabilization? (3 points)

   Answer:
   Weight loss counselling
   Reduce refined carbohydrates
   Reduce saturated fat intake
   Minimize alcohol use
   Fibrate therapy
   Statin therapy if ASCVD risk is elevated
   High-dose omega-3 fatty acids (e.g., 4 g/day)
   Optimize diabetes and thyroid control

4. Which medication is considered first-line for the prevention of recurrent pancreatitis in severe hypertriglyceridemia? (1 point)
   1. Ezetimibe
   2. Fibrate
   3. PCSK9 inhibitor
   4. Bile acid sequestrant
   5. Aspirin

   Answer: B

5. Which of the following statements about emerging therapies is most accurate? (1 point)
   1. Plozasiran is approved in Canada for all dyslipidemias
   2. Plozasiran targets APOC3 and is approved for familial chylomicronemia syndrome
   3. Statins are superior to fibrates for severe triglyceride lowering
   4. Evinacumab is approved in Canada specifically for hypertriglyceridemia
   5. Niacin is the preferred first-line agent

   Answer: B (Fibrates and apolipoprotein C inhibitors produce the most substantial reductions in triglyceride levels, whereas statins and icosapent ethyl are primarily used to lower atherosclerotic cardiovascular disease risk in patients with hypertriglyceridemia)

Helpful CMAJ Resource:
https://www.cmaj.ca/content/198/16/E622