Hypertriglyceridemic Pancreatitis: Is Insulin Monotherapy A Feasible Therapeutic Option?

Acute Pancreatitis, Hypertriglyceridemia, and Diabetic Ketoacidosis: A Life-Threatening Triad

Hypertriglyceridemia (HTG)-induced pancreatitis is a known complication of uncontrolled diabetes mellitus (DM). However, the coexistence of diabetic ketoacidosis (DKA) and acute pancreatitis in the presence of HTG is rare and presents diagnostic and therapeutic challenges. We present the case of a 42-year-old female with poorly controlled type 2 DM who developed severe HTG-induced pancreatitis complicated by DKA. She initially presented with abdominal pain, metabolic acidosis, and marked hyperglycemia. Subsequent investigations revealed significantly elevated serum triglyceride and lipase levels and characteristic findings of acute pancreatitis on imaging. This case report highlights the complex interplay of metabolic disturbances in diabetes and the importance of timely recognition and tailored management to achieve a successful outcome.

Analysis of Intravenous Insulin Dosing Requirements for Treatment of Severe Hypertriglyceridemia

Purpose: Insulin infusion therapy is commonly utilized for treatment of severe hypertriglyceridemia, however, data supporting a standardized dosing approach is lacking. This study aimed to determine the average initial insulin dose utilized for treatment of hypertriglyceridemia and the associated reduction in serum triglycerides. Methods: This single-center, retrospective, descriptive analysis conducted at an academic medical center included adult hospitalized patients with serum triglyceride levels greater than 1000 mg/dL receiving treatment with an intravenous insulin infusion between November 2017 and August 2020. Data was extracted from the electronic medical record. The primary outcome was the mean weight-based intravenous insulin dose resulting in resolution of hypertriglyceridemia. Secondary outcomes included time to resolution of hypertriglyceridemia, adverse events associated with insulin treatment, incidence of rebound hypertriglyceridemia, and use of additional lipid-lowering therapies. Results: Data from 32 hospital encounters was analyzed. The mean initial triglyceride level was 3229 mg/dL. The average insulin doses observed on days 1 and 2 of therapy were 0.07 and 0.05 units/kg/hour, respectively. The mean percent triglyceride reduction at 48 hours was 40%. Mean time to resolution of hypertriglyceridemia, discontinuation of insulin infusion, or discharge was 5.7 days. Hypoglycemia and hypokalemia were observed in 9% and 29% of patients, respectively. Conclusion: The results of this study provide new guidance for insulin dosing for hypertriglyceridemia. Serum potassium levels and blood glucose should be monitored closely during therapy.

Safety and Efficacy of Insulin and Heparin in the Management of Hypertriglyceridemia-Induced Pancreatitis in a Patient without Diabetes: A Case Report

Acute pancreatitis (AP) leads to a variety of complications, such as local or systemic inflammatory responses as well as organ failure. While choledocholithiasis and alcohol abuse are two of the most common causes of AP, hypertriglyceridemia causes AP with an incidence rate between 2 and 5%. The management of hypertriglyceridemia-induced pancreatitis (HTGIP) is focused on the lowering of triglyceride (TG) levels, and the efficacy of therapies for the management of HTGIP may vary based on the hypertriglyceridemia etiology. The aim of this article is to report a case of a 43-year-old female with a history of familial hypertriglyceridemia and without diabetes who was admitted for acute pancreatitis with a TG level elevated to 4,435 mg/dL. The patient was treated with a combination of insulin, heparin, atorvastatin, and omega-3-acid ethyl esters, and her TG level was reduced to 880 mg/dL after 9 days of therapy. Despite the successful treatment of the patient, standardization of the approach for the treatment of HTGIP is needed. Future research should aim to identify the appropriateness of insulin therapy specifically in patients without diabetes presenting with hypertriglyceridemia and the dosing associated with optimal safety.

A Case of Recurrent Acute Pancreatitis Secondary to Hypertriglyceridemia

Hypertriglyceridemia is known to be the third most common etiology of acute pancreatitis. Triglyceride levels above 1,000 mg/dL are associated with an increased risk of acute pancreatitis. We present the case of a 22-year-old female, a known case of hypertriglyceridemia, who developed sudden onset severe epigastric abdominal pain. A marked elevation in triglyceride levels of >3,000 mg/dL, serum lipase levels of 722 U/L, and serum amylase levels of 161 U/L, in the absence of other risk factors of acute pancreatitis, suggested hypertriglyceridemia-induced acute pancreatitis. Computed tomography (CT) of the abdomen and pelvis with contrast confirmed acute pancreatitis with hepatic steatosis. She was initially placed nil per os (NPO) and intravenous (IV) fluids with normal saline were administered. However, she was subsequently transferred to the intensive care unit as she developed acute respiratory distress syndrome. She was started on IV insulin with 5% dextrose in normal saline and a hydromorphone hydrochloride patient-controlled analgesia (PCA) pump was used for pain control. The patient's condition improved gradually. At the time of discharge, the triglyceride (311 mg/dL) and lipase levels (81 U/L) of the patient were within the normal range. The prognosis of hypertriglyceridemia-induced acute pancreatitis is considered to be worse than non-hypertriglyceridemic acute pancreatitis. Patients with hypertriglyceridemia-induced acute pancreatitis need swift diagnosis and treatment to avoid serious complications.

Hypertriglyceridemia-Induced Pancreatitis Complicated by Diabetic Ketoacidosis

Acute pancreatitis is a potentially fatal clinical entity having multiple underlying triggers. Though the incidence of hypertriglyceridemia-induced pancreatitis is low; however, patients with such risk factors develop severe disease. We present a case of a 47-year-old male who came to our facility with complaints of epigastric pain. Physical examination and laboratory workup unmasked the presence of pancreatitis alongside concurrent diabetic ketoacidosis (DKA). This presentation is unique, and to our knowledge, only a few cases have been reported in the literature. Furthermore, the co-existence of pancreatitis and DKA can overlap the clinical picture of each other, which might lead to unwanted complications if not diagnosed timely.

Current Diagnosis and Management of Primary Chylomicronemia

Primary chylomicronemia (PCM) is a rare and intractable disease characterized by marked accumulation of chylomicrons in plasma. The levels of plasma triglycerides (TGs) typically range from 1,000 - 15,000 mg/dL or higher.

PCM is caused by defects in the lipoprotein lipase (LPL) pathway due to genetic mutations, autoantibodies, or unidentified causes. The monogenic type is typically inherited as an autosomal recessive trait with loss-of-function mutations in LPL pathway genes ( LPL , LMF1 , GPIHBP1 , APOC2 , and APOA5 ). Secondary/environmental factors (diabetes, alcohol intake, pregnancy, etc.) often exacerbate hypertriglyceridemia (HTG).

The signs, symptoms, and complications of chylomicronemia include eruptive xanthomas, lipemia retinalis, hepatosplenomegaly, and acute pancreatitis with onset as early as in infancy. Acute pancreatitis can be fatal and recurrent episodes of abdominal pain may lead to dietary fat intolerance and failure to thrive.

The main goal of treatment is to prevent acute pancreatitis by reducing plasma TG levels to at least less than 500-1,000 mg/dL. However, current TG-lowering medications are generally ineffective for PCM. The only other treatment options are modulation of secondary/environmental factors. Most patients need strict dietary fat restriction, which is often difficult to maintain and likely affects their quality of life.

Timely diagnosis is critical for the best prognosis with currently available management, but PCM is often misdiagnosed and undertreated. The aim of this review is firstly to summarize the pathogenesis, signs, symptoms, diagnosis, and management of PCM, and secondly to propose simple diagnostic criteria that can be readily translated into general clinical practice to improve the diagnostic rate of PCM. In fact, these criteria are currently used to define eligibility to receive social support from the Japanese government for PCM as a rare and intractable disease.

Nevertheless, further research to unravel the molecular pathogenesis and develop effective therapeutic modalities is warranted. Nationwide registry research on PCM is currently ongoing in Japan with the aim of better understanding the disease burden as well as the unmet needs of this life-threatening disease with poor therapeutic options.

Acute pancreatitis secondary to cocaine use: a case-based systematic literature review

Cocaine use continues to be an important global public health problem. As the use of cocaine remains pervasive so have a myriad of adverse events associated with this drug. These deleterious effects are well-studied, but gastrointestinal complications remain esoteric and the existing clinical evidence is scarce. Ischemia of the esophagus and small bowel, perforation, peptic ulceration, gastrointestinal bleeding, and ischemic colitis are among the reported complications. In specific, acute pancreatitis secondary to cocaine use is an exceedingly rare clinicopathologic entity. To date, only 7 cases of this condition have been reported in the English-language literature. We hereby delineate a rare case of a 29-year-old female who developed her first episode of cocaine-associated pancreatitis. The diagnosis was made based on a standard battery of investigations and meticulous exclusion of common etiologies of acute pancreatitis. To our knowledge, this case represents the first report of re-occurrence of acute pancreatitis upon subsequent crack cocaine insufflation, adding a higher level of evidence to a fallible association. We also present a systematic review of the existing literature on acute pancreatitis following cocaine use. An updated knowledge regarding this rare association is of paramount importance for early diagnosis and astute management.

Diabetic ketoacidosis with acute severe hypertriglyceridaemia-induced pancreatitis as first presentation of type 2 diabetes

Acute pancreatitis (AP) is an acute destructive inflammatory condition of the pancreas. Hypertriglyceridaemia is the third most common worldwide cause of AP. Although the presentation of hypertriglyceridaemic pancreatitis (HTGP) is usually similar to other forms of AP, it may cause more severe AP and worse symptoms. Therefore, apart from the supportive care and treatment for AP, it is necessary to treat the underlying aetiology. There are no established guidelines for managing HTGP. Many treatment modalities have been reported, including intravenous insulin infusion, heparin and plasmapheresis. Randomised trials comparing their efficacy are lacking. Diabetic ketoacidosis (DKA) may be a risk factor for AP, but it is uncertain if AP triggers DKA or vice versa. Here, we describe a case of a 44-year-old man who presented with DKA concurrent with acute severe HTGP as first manifestation of type 2 diabetes mellitus. He was successfully managed with supportive care and intravenous insulin infusion.

Hypertriglyceridemic Pancreatitis Treated with Insulin Therapy: A Comparative Review of 34 Cases

Although the clinical presentation of hypertriglyceridemic pancreatitis is usually similar to other forms of acute pancreatitis, it is frequently associated with increased clinical severity and rate of complications. Therefore, appropriate and timely management is of paramount importance in these patients. We performed a structured literature search of the medical databases PubMed and Google Scholar, using the terms “hypertriglyceridemia,” “acute pancreatitis,” “insulin,” and “treatment.” In this search, we identified 34 cases of hypertriglyceridemia-related pancreatitis available in the full-text form in English. The data on patients’ characteristics, epidemiology, clinical features, comorbid conditions, and diagnostic modalities were collected and summarized. This review illustrates that the use of insulin therapy with close monitoring of blood glucose levels is safe. It can be considered as an important component of management in patients with hypertriglyceridemia-related pancreatitis, especially in a clinical setting without the availability of plasmapheresis. Randomized clinical trials are warranted to outline a generalized and efficient treatment regimen for hypertriglyceridemic pancreatitis.