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APP Strategies in sHTG and FCS
Improving Outcomes in sHTG or FCS With APP-Led Strategies

Released: December 15, 2025

Nicole A. Ciffone
Nicole A. Ciffone, MSN, ANP-C FNLA
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Key Takeaways
  • Patients with sHTG and FCS are frequently misunderstood with many being misdiagnosed and receiving improper management.
  • APPs play a critical role in early identification, intervention, and ongoing management for patients with sHTG and FCS.
  • Although patients with FCS were historically managed solely with a highly restrictive low-fat diet, novel therapies are now available that may reduce the burden on these patients.

Advanced practice providers (APPs) like nurse practitioners and physician associates are uniquely positioned to change the trajectory of care for patients with severe hypertriglyceridemia (sHTG) or familial chylomicronemia syndrome (FCS). As frontline healthcare professionals (HCPs), APPs are experts in chronic disease management and are often the first to recognize warning signs, initiate early intervention, and build the relationships that sustain long-term disease control. Their ability to pair evidence-based clinical strategies with personalized lifestyle counseling enables APPs to reduce patients’ cumulative exposure to dangerously high triglycerides and prevent the serious complications that follow. By helping patients navigate treatment options, overcome barriers to adherence, and stay engaged in their care, APPs play a pivotal role in improving outcomes in these high-risk populations.

Long-term Risks of Persistently High Triglycerides
When patients have persistently high triglycerides, this can put them at risk for cardiovascular disease and other more potentially and immediately life-threatening diseases, such as recurrent pancreatitis. It is well known that patients can die of pancreatitis if it is not recognized or intervened upon early. Severely elevated triglycerides, such as levels in the thousands, can damage the pancreas, and you only get 1 pancreas in a lifetime. You do not have a backup. So we need to take care of the pancreas and intervene when issues arise before long-term damage occurs.

Unfortunately, HCPs often assume that sHTG only concerns patients’ carbohydrate intake or is related to diabetes. But when triglyceride levels are in the thousands, HCPs must recognize that there is something else going on. Much of this also has to do with the role of dietary fats, not just carbohydrates. There also could be a genetic issue (ie, FCS) impacting the way in which patients metabolize dietary fats. In FCS, patients cannot process or metabolize the particles that are full of triglycerides via normal pathways, leading them to be at extreme risk for developing acute pancreatitis, damage to the pancreas, and subsequent diabetes. With sHTG and FCS, patients present with elevated triglycerides that can cause them to develop diabetes later on due to ongoing damage to the pancreas.

APP-Led Strategies for Improving Patient Care
Considering the risks outlined above, APPs who are managing patients with sHTG or FCS should monitor their labs over time and tune in to the symptoms they report in follow-up. In thinking about common symptoms, I ask patients if they experience any gastrointestinal-related symptoms, brain fog, or depression, especially after eating fatty foods. It is important to understand that patients may not realize that they are experiencing these symptoms until you ask them about it directly.

For a long time, we only had dietary management as a treatment strategy for FCS. This strategy remains a cornerstone of patient care because of the difficulty patients have with metabolizing dietary fats. These patients are required to follow a very–low fat diet, and when I say “very low,” I mean less than 10 g daily. This is extremely difficult to adhere to since there are hidden sources of fat that make this diet incredibly restrictive and further affect patients' lives. Therefore, patients who we label as nonadherent really may not have the capacity to be adherent based on their disease state. When your blood looks like a strawberry milkshake, how do you think that looks? How do you think that feels when it is going through the small vessels in your brain and other organs? For example, I had a patient in for a visit and I almost thought he had dementia due to the lack of clarity while he was telling his story. I started him on a new therapy that we have for FCS, and his triglycerides dropped from over 4000 to less than 300 mg/dL. The patient noted that what stood out to him most was clarity of thought; it was like he was a different person.

I had another patient who needed plasmapheresis. Once we got her triglycerides down, she reported clarity of thought. She also felt her previous issues with depression and attention deficit cleared up, as she was now able to focus and organize her medications and meal plan. That is why I spend a lot of time asking patients about stomach upsets, bloating, and a gastroparesis-type feeling. APPs should develop deeper relationships with patients to help them identify the symptoms they are experiencing and dive into what is going on with their diet and lifestyle.

A note about diabetes. We are currently in a type 2 diabetes epidemic; it is so prevalent, and the number is increasing. The clue that high triglycerides in a patient may not be your garden variety (ie, mixed hyperlipidemia, diabetic dyslipidemia) is when triglyceride levels are over 800 mg/dL. When triglyceride levels reach 4 digits—that is, into the thousands—this could indicate that it may not just be carbohydrates that are the issue. It may also be related to dietary fats, and that is a key point that will help HCP manage these patients.

Specialty Care and Novel Therapies
As a lipid specialist, I see patients after other treatments have failed them. This makes sense because patients with sHTG or FCS have a mechanism that is different and explains why other treatments do not work. Again, HCPs may suspect that patients are not adhering to their treatment, but many times these treatments simply fail to work because they were not targeting the right pathway. Now that we have therapies that are really focusing more on what is going on with the lipoprotein lipase (ie, targeting apoC-III), they allow for lipoprotein lipase to have more action on these particles and get the triglycerides out of the chylomicron. Therefore, patients can process triglycerides better. Furthermore, these therapies require simple injections. They are targeted, well-tolerated, and have an established safety profile.

Because FCS is a rare genetic disease, we must communicate with other specialists, like dietitians and pharmacists, about the challenges that these patients may face. The needs of patients with FCS or sHTG with or without comorbid diabetes are different than the average patient with diabetes. That may require HCPs to help other specialists, the healthcare team, and patients to understand what is going on because a rare disease like this can be misunderstood easily. Patients can also be misunderstood. They can present to the hospital or emergency department with abdominal pain and high triglycerides and be misjudged or miscategorized by the attending HCP.

Follow-up and Multidisciplinary Care
HCPs must create clear monitoring plans that are informed by the current standard of care and what is recommended for each of the new therapies. Finding a dietitian well versed in managing patients with FCS is also imperative.

Then there are pharmacists, who can be retail or specialty pharmacists, but since these treatments are administered via injection, you likely will deal with specialty pharmacists. They can provide a whole different level of access to information for HCPs and patients. They also can help with finding ways to get these therapies into patients’ hands, so they are excellent resources. Managing patients with sHTG or FCS truly requires a multidisciplinary, team-based approach. 

Your Thoughts
Do you provide multidisciplinary care to your patients with sHTG or FCS? You can get involved in the conversation by answering the poll question and posting a comment below.

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Do you coordinate with a multidisciplinary team when managing patients with sHTG or FCS?

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