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Abstract

Introduction: Hypertriglyceridemia-induced pancreatitis (HTGP) is associated with a higher severity of illness and more complications than acute pancreatitis (AP) without hypertriglyceridemia (HTG). Diabetic ketoacidosis (DKA) may be a risk factor for AP, but it is uncertain if AP triggers DKA or vice-versa. We describe a patient with DKA and AP managed with continuous IV insulin and apheresis. A 30 year-old male with type 1 diabetes, familial HTG, and AP presented with a 10 day history of worsening epigastric pain. Laboratory and imaging studies were consistent with HTGP and DKA. He was started on IV insulin and intubated for respiratory distress. On day 2 ketosis resolved, but he was continued on IV insulin for HTGP. Renal replacement therapy was started for acute kidney injury. Due to severity of illness and lack of adequate response to insulin, apheresis was initiated. After 2 sessions, TG decreased from 3362 mg/dl to 192 mg/dl. On day 9 he was transitioned from IV to subcutaneous insulin and TG remained <500 mg/dl. The remainder of his hospitalization was complicated by severe hemorrhagic pancreatitis, candidemia, and pneumonia. On day 11 he was extubated and on day 17 he left the ICU. On day 38 he was discharged on insulin detemir and omega-3 fish oil. The relationship between AP, DKA, and HTG is complicated, making identification of the primary cause difficult. AP can exacerbate DKA and moderate HTG in DKA is common. Optimal management of these patients is unknown since there are no large trials or consensus statements to guide treatment. Common strategies include apheresis and insulin. As seen in our patient, use of apheresis results in immediate reduction in TG levels, but large well-conducted trials are necessary to support this practice. Use of IV insulin to control DKA and HTGP appears safe and effective. However, once ketosis resolves and blood glucose normalizes, the insulin infusion may be inappropriately stopped while TG are still critically elevated. Thus, communication of clear goals of therapy is paramount. Although the most appropriate length of time to provide IV insulin is uncertain, it is reasonable to continue therapy until TG <1000 mg/dl.