Severe hypertriglyceridemia induced acute pancreatitis: Management strategy in a rural setup.

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Conference Proceeding

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Publication Title

J Gen Intern Med


LEARNING OBJECTIVE #1: Intravenous Insulin has similar efficacy to plasmapheresis in emergent management of HTG induced AP LEARNING OBJECTIVE #2: Patients with TG > 500 mg/dl are recommended to undergo genetic testing to rule out disorders associated with lipid metabolism. CASE: 44 year old male with history of diabetes mellitus and hypertension presented with severe epigastric abdominal pain radiated to the back associated with several episodes of vomiting for past 24 h. He denies fever, chills, diarrhea, black tarry stools and weight loss. He denied history of excessive alcohol use. His medications included metformin and insulin glargine. On presentation he was vitally stable and had generalized abdominal tenderness, audible bowel sounds with no palpable hepatosplenomegaly. Labs revealed lipase of 5006 U/L (50-290 U/L), amylase of 299 U/L (30-110 U/L). CT abdomen revealed moderate peri-pancreatic edema concerning for acute pancreatitis (AP). Triglycerides levels (TG) were severely elevated to 6672 mg/dl (55-150 mg/dl). He was started on conventional treatment of AP with IV hydration and analgesia. Given our rural setup and absence of availability of plasmapheresis (PP) for rapid correction of HTG, patient was started on insulin infusion 0.1 units/kg/hr along with D5W to maintain euglycemia. He was continued on that regimen with hourly blood glucosemonitoring until TG were <500 mg/dl which was achieved on day 8. He was discharged on atorvastatin and fenofibrate with a referral to a lipidologist to rule out genetic causes of hypertriglyceridemia (HTG). IMPACT: In a clinical setup where PP is not readily available for acute management of HTG induced AP, use of IV insulin with IV dextrose is an effective alternative treatment strategy. Rapid reduction in TG levels to <500 mg/dl is associated with improved clinical outcomes. DISCUSSION: HTG is the third most common cause and is responsible for almost 1-4% of AP. The incidence of AP in patients with TG > 2000 up to 20. In patients who developed an episode of AP secondary to severeHTG, the goal is to bring the TGless than 500 as early as possible because it is associated with improved clinical outcome. PP is usually considered first-line therapy for severe HTG with many studies supporting its clinical utility. In a case series of 7 patient, 41% decrease in TG was reported with single plasma exchange. In absence of availability of PP, alternate treatment modalities with intravenous (IV) insulin should be considered. Standard approach is 0.1-0.3 units/kg/hr of regular insulin IValong with dextrose saline to maintain euglycemia until TG come down to <500. There are no randomized controlled trials which compare efficacy of insulin with PP in treatment of severe HTG. Therefore, treatment is usually based on availability and preference. Long-term goal for patients who had episodes of AP secondary to HTG, is to prevent further episodes by optimizing lipid lowering therapy and lifestyle modification. Non-compliant patients may need periodic PP to prevent episodes of AP.





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