SUN-167 Quetiapine-Induced Hypertriglyceridemia and Hyperglycemia Presenting as Simultaneous Diabetic Ketoacidosis and Acute Pancreatitis

Abstract

Background: Quetiapine-induced metabolic emergencies such as diabetic ketoacidosis (DKA) and acute pancreatitis (AP) are rare. We describe a case of new-onset hypertriglyceridemia (HTG) and diabetes mellitus (DM) following the initiation of quetiapine, presenting as concurrent new-onset DKA and AP. Clinical Case: A 34 year-old male with bipolar disorder and schizophrenia presented with three days of epigastric pain, nausea, and vomiting. He had no prior history of DM or dyslipidemia (DLD). He reported long-standing use of divalproex, benztropine, and haloperidol. He had started quetiapine three months prior, at which time glycosylated hemoglobin A1c (HgbA1c) was 5.7% and non-fasting triglyceride (TG) level was 266 (range 30-150 mg/dL). He was a smoker, but denied alcohol or drug use. On admission, he was hypertensive, tachycardic, and febrile with significant abdominal pain. His blood glucose was 522 (range 55-110 mg/dL) with an anion gap of 27 (range 5-17), venous pH of 7.18 (range 7.33-7.43), bicarbonate of 7 (range 23-31 mEq/L), and serum creatinine of 1.8 (0.6-1.4 mg/dL). He also had an elevated serum lipase of 317 (range 5-55 U/L), TG of 2436 (range 30-150 mg/dL), and computed tomography confirmed peri-pancreatic edema consistent with AP. Thyroid function tests were normal. Abdominal ultrasound was negative for cholelithiasis. He was treated with aggressive intravenous (IV) hydration and IV insulin, and later transitioned to subcutaneous (SQ) insulin after resolution of DKA. Quetiapine was stopped and he was discharged on haloperidol, benztropine, fenofibrate, and SQ insulin. Due to improving BG levels, insulin was gradually tapered over the next few weeks and subsequently discontinued. HgbA1c obtained three months later was 5.7% (off insulin) and fasting TG level was 212 mg/dL. Discussion: Second generation antipsychotics (SGAs), particularly olanzapine and clozapine, are known to cause metabolic abnormalities such as weight gain, hyperglycemia, and hyperlipidemia. Although quetiapine is described to have low risk for development of diabetes or lipid abnormalities, it can cause life-threatening complications like DKA and AP. While DKA has been reported in many case series, AP is exceedingly rare. There are fewer than ten reported cases with or without HTG following quetiapine use, usually within the first year of drug initiation. Since many of these patients do not have pre-existing DLD or DM, it is important for providers and patients to be aware of the risk of developing these life-threatening complications, even with a relatively safe SGA. Current guidelines recognize the importance of laboratory monitoring for early detection of metabolic disturbances in patients taking SGAs; however, recommendations regarding frequency of monitoring remain variable. Updated surveillance parameters are needed to facilitate the prevention of such metabolic emergencies.