Recurrent Hypertriglyceridemic Pancreatitis (HTGP); and the Use of Insulin Drip as Treatment.

Abstract

Introduction: Chronic pancreatitis by definition is a recurrent episode of acute pancreatitis and is commonly associated with alcoholism in the US. Another cause of chronic pancreatitis is hypertriglyceridemia (HTGP);, occurring in 1-5 percent of cases. The incidence of HTGP is higher in patients with diabetes and HIV, usually requiring triglyceride levels > 1000 mg/dL.

Case: A 33 year old man with uncontrolled type 1 diabetes and recurrent pancreatitis, first diagnosed 5 years prior, presented as a transfer from an outside hospital for a recurrent episode of HTGP. He reported recurrent pain episodes, requiring 6-9 hospitalizations within the last year for pancreatitis. He reported poor compliance with his insulin regiment at home. Other home medications included gemfibrozil, lisinopril, niacin, and omega-3 fatty acid. On transfer, his glucose was 296, triglyceride level was >3600, and A1C of 12.4. Transfer report lab work showed a triglyceride level >7000 and a lipase of 600. The patient had severe, diffuse abdominal tenderness on examination. He was diagnosed with pancreatitis secondary to hypertriglyceridemia due to a lipoprotein metabolism disorder and long-standing uncontrolled DM1. An intensive insulin drip was started on this patient, with goals of correcting his TG to less than 500 along with lowering his glucose. After 13 days, mostly on insulin drip, his TG decreased to 995 and pain was controlled, eventually tolerating a diabetic diet. He was encouraged to modify his diet and take his medications as directed at discharge.

Discussion: The relationship between hypertriglyceridemia and pancreatitis is poorly understood. In HTGP, a decrease in triglyceride concentration is a management priority. Rapid triglyceride concentration lowering is managed by insulin or plasmapheresis. As HTGP often presents in patient with uncontrolled diabetes, insulin is frequently used as treatment to lower both blood glucose and triglycerides; insulin decreases serum triglyceride levels by enhancing lipoprotein lipase activity and inhibiting hormone sensitive lipase, accelerating metabolism and decreasing adipocyte breakdown. Patients should be educated on the importance of compliance with drug therapy and lifestyle modifications.