S1447 Treatment of Severe Hypertriglyceridemia-Induced Pancreatitis With Insulin Drip

Abstract

INTRODUCTION: Severe elevation of serum triglycerides (TG) is associated with a high morbidity and mortality, worldwide. TG levels greater than 1000 mg/dl predispose to the development of acute pancreatitis and require urgent treatment. The breakdown of TG by pancreatic enzymes releases free fatty acids, activates trypsinogen resulting in inflammation of the pancreas. Treatment with IV insulin promotes synthesis of lipoprotein lipase leading to rapid reduction of TG levels. We present a case of severe hypertriglyceridemia induced pancreatitis treated with IV insulin despite meeting criteria for apheresis therapy. CASE DESCRIPTION/METHODS: /Methods 30 years old male with history of diabetes presented with abdominal pain and vomiting. Physical exam was remarkable for tenderness in the epigastric. Labs revealed metabolic acidosis due to beta-hydroxybutyrate and elevated lipase. CT abdomen confirmed the diagnosis of pancreatitis. No history of alcohol abuse and abdominal ultrasound was unremarkable. Serum triglyceride level was >4425 mg/dl. The patient did not have lactic acidosis, hypocalcemia, however he did have >2 signs of inflammation. IV insulin was started to treat diabetic ketoacidosis as well as hypertriglyceridemia. Over the course of three days, the triglyceride level dropped to 579 mg/dl and IV insulin was switched to subcutaneous insulin. The triglyceride reduction rate was maxed at 118 mg/dL/h at the beginning of insulin therapy and slowest at 51 mg/dL/h at the end of treatment. The patient was started on Fenofibrate and Atorvastatin therapy prior to discharge. He was instructed to test for primary causes of severe hypertriglyceridemia. DISCUSSION: The indications for lipid apheresis include TG >1000 mg/dl, serum lipase greater than three times the upper limit, severe hypocalcemia, lactic acidosis, worsening inflammation, or organ dysfunction. Despite meeting criteria for apheresis therapy, the patient’s serum TG were safely and effectively lowered below 500 with insulin drip over the course of three days, without any adverse effects. In current guidelines there is no consensus on first line therapy. Observational studies have compared the efficacy as well as risks vs benefits of both therapies, showing promising results for insulin. However, more research is required in large scale centers. Insulin drip should be considered as an effective treatment of HTG induced pancreatitis in select patients to minimize invasive procedures and the risks associated with them.Figure 1.: A trend of serum triglyceride level while receiving IV insulin drip.