- ~5% of acute pancreatitis caused by high triglycerides
- TG levels > 2000mg/dL almost always have both secondary and genetic form
- 1.7% of US estimated to have [TG] between 500-2000
- May present with normal serum lipase levels
- Excess TG hydrolyzed by increased concentration of pancreatic lipase
- Produces increased concentration of free fatty acids that exceeds binding capacity of albumin
- Micelles are formed that attack platelets, vascular endothelium and acinar cells
- Ischemia and pancreatic injury result
- An acidic environment potentiates free fatty acid toxicity
Management of acute pancreatitis in the setting of hypertriglyceridemia
- Evidence for management based on case series and reports
- Insulin drip - most dramatic and rapid intervention, with reduction within 24 hrs
- 5-10 units/hr with or without dextrose infusion to maintain BSs ~150mg/dL
- May require higher dosages for diabetics, 0.1–0.3 U/kg/hr
- Titrate to BS 140–180mg/dL
- Treat concurrent hypothyroidism if present
- Pain control
- Niacin 500mg QD
- Gemfibrozil or fenofibrate
- Max dose statin, 81mg ASA
- Heparin q8 SC, effect short-lived
- NPO initially
- May advance diet starting at TG level < 1000mg/dL with resolution of abdominal pain/pancreatitis symptoms
- No fat diet
- Low calorie diet
- Follow TG levels, goal < 500-1000mg/dL by discharge
- Therapeutic plasma exchange, for 1-3 days (sickest patients)
- For euglycemic patients, not routine first line
- Requires central venous access
- Asymptomatic hypertriglyceridemia is treated as an outpatient
- For acute pancreatitis, ICU or step-down for frequent labs, insulin drip
- Yadav D, Pitchumoni CS. Issues in hyperlipidemic pancreatitis. J Clin Gastroenterology 2003;36:54-62.
- Yuan et al. Hypertriglyceridemia: its etiology, effects and treatment. CMAJ 2007;176:1113-1120.
- Brown, Virgil W. Et al. “Clinical Lipidology Roundtable Discussion: Severe Hypertriglyceridemia.” Journal of Clinical Lipidology 2012; 6:397-408
- Santana YR et al. Treatment of severe hypertriglyceridemia with continuous insulin infusion. Case Reports in Critical Care. June 2011.
- Poonuru S et al. Rapid Reduction of Severely Elevated Serum Triglycerides with Insulin Infusion, Gemfibrozil and Niacin. Clin Med Res. 2011 Mar; 9(1): 38–41.
- Schaefer EW. Management of Severe Hypertriglyceridemia in the Hospital: A Review. Journal of Hospital Medicine Vol 7|No 5|May/June 2012.