Intensive Insulin Therapy for Hypertriglyceridemic Pancreatitis

Introduction: Pancreatitis can be triggered by many factors with one rare etiology being Hypertriglyceridemia.Duration of Hypertriglyceridemia and the levels determine the severity and here we present one such case treated successfully with Insulin management. Case Description/Methods: A 34 year old man with Insulin-Dependent Diabetes Mellitus Type II and Hypertriglyceridemia presented with symptoms and signs of acute pancreatitis. Biochemical analysis yielded a Sodium of 123 mmol/L, Lipase of 1883 unit/L, Triglycerides of 7171 mg/dl. CT abdomen confirmed acute pancreatitis with hepatic steatosis. He was admitted to the ICU and was started on Insulin drip + D5LR. Triglycerides was monitored every 12 hours along with Blood glucose every 2 hours with goal at 140-180 mg/dl. Triglycerides decreased by > 60% in the first 24 hours along with expected resolution of Pseudohyponatremia. Intravenous insulin was transitioned to Subcutaneous insulin once TG< 500 mg/dl with resumption of diet and the addition of Fenofibrate 200 mg and Rosuvastatin 10 mg. He was discharged on Day 6 in a stable condition with Endocrinology follow-up. Discussion: Acute Pancreatitis can be diagnosed with acute abdominal pain and tenderness, significant elevation of pancreatic enzymes and/or abnormal imaging findings.Hypertriglyceridemia approximately accounts for 1-7% of all etiologies of pancreatitis.Hypertriglyceridemia could be a familial trait in combination with dyslipidemia, or can occur secondary to uncontrolled diabetes mellitus, obesity, alcohol consumption or estrogen therapy. TG >2000 mg/dl usually has a genetic component coupled with a secondary cause. Hydrolysis of Triglycerides by Lipase promotes accumulation of Free Fatty acids leading to Pancreatic capillary plugging and resulting in ischemia and acidosis that activates trypsinogen and its accompanying inflammatory cascade. Intravenous insulin stimulates and activates Lipoprotein lipase which degrades chylomicrons and thus reduces Triglyceride levels. Plasmapheresis is an alternative approach in management of Hypertriglyceridemia, however the cost and the availability of this modality remains a limiting factor and its superiority over Insulin is not well established. Therefore, along with lifestyle modification and fibrates for long-term management, we recommend treatment of Hypertriglyceridemia-induced pancreatitis with intravenous insulin for rapid reduction of triglyceride levels in order to decrease hospital stay and reduce the morbidity and mortality associated with pancreatitis.Figure 1.: 1) CT Abdomen showing the extent of Pancreatitis 2) Reduction in Triglyceride levels during the hospital course 3) Sodium trend during the same period.