Continuous insulin therapy versus apheresis in patients with hypertriglyceridemia-associated pancreatitis

Abstract

Background The optimal treatment modality for lowering the triglyceride level in patients with hypertriglyceridemia (HTG)-associated acute pancreatitis is unknown. We evaluated the efficacy of continuous insulin infusion and apheresis procedures as triglyceride-lowering therapy. Materials and methods Clinical, demographic, and laboratory data were retrospectively evaluated for patients with HTGassociated pancreatitis who received continuous insulin infusion or apheresis in a single tertiary center. The endpoints were modality effectiveness and clinical outcomes. ResultsThe study included 48 patients (mean age, 40.4 ± 9.9 years). Apheresis and insulin infusion were performed in 19 and 29 patients, respectively, in the first 24 h of hospital admission. Apheresis procedures included therapeutic plasma exchange in 10 patients and double filtration plasmapheresis in nine patients. Baseline mean triglyceride level was higher in the apheresis group. The two groups were similar in terms of other baseline clinical and demographic characteristics. Seventeen patients (58.6%) in the insulin group and nine patients (47.4%) in the apheresis group exhibited Balthazar grades D-E. There was a rapid reduction (78.5%) in triglyceride level after the first session of apheresis. Insulin infusion resulted in a 44.4% reduction in mean triglyceride level in the first 24 h. The durations of fasting and hospital stay, and the rates of respiratory failure and hypotension, were similar between groups. More patients in the apheresis group experienced acute renal failure or altered mental status. Prognosis did not significantly differ between groups. Conclusion Although apheresis treatments are safe and effective, they provided no clear benefit over insulin infusion for HTG-associated pancreatitis.

Comparable Triglyceride Reduction With Plasma Exchange and Insulin in Acute Pancreatitis – A Randomized Trial

“…There were rare attempts in the literature at a controlled comparison of PE with conservative treatments, showing greater triglyceride lowering with PE in some ( 8 , 13 , 17 , 22 ) but not all reports ( 23 , 24 ). E.g., we have shown a 59% vs. 27% daily reduction in triglycerides with PE as compared to fasting-only 24-hour periods in between PE treatments ( 8 ), with the limitation, that the fasting periods usually did not occur on the day of admission and that the% reduction in triglycerides is likely higher with higher baseline triglyceride level.…”

“…E.g., we have shown a 59% vs. 27% daily reduction in triglycerides with PE as compared to fasting-only 24-hour periods in between PE treatments ( 8 ), with the limitation, that the fasting periods usually did not occur on the day of admission and that the% reduction in triglycerides is likely higher with higher baseline triglyceride level. Another retrospective study found a significantly higher baseline triglycerides in the apheresis group and comparable levels after 24 h, resulting in a 79% decrease with apheresis versus 44% with insulin infusion ( 17 ). In a relatively large propensity score-matched cohort of patients, a modest but significantly greater reduction in triglycerides was seen with DFPF (80%) versus conservative treatment (72%), which included insulin only in cases of hyperglycemia ( 13 ); a result comparable to this study.…”

“…The validity of a fast reduction of triglycerides itself as a surrogate treatment goal could also be questioned, as the final goal of treatment is amelioration of the severity of pancreatitis. Data on the effect of PE on the clinical course of pancreatitis are even more scarce, but none show a convincing benefit of PE ( 21 – 23 ), not event in studies, where greater reduction of triglycerides was observed with PE ( 13 , 17 ). Several large randomized trials are currently underway to address the issue of hard clinical end-points in the treatment of HTG-AP with either PE, insulin or fasting alone, which will provide more definitive data in the next few years ( 30 , 31 ).…”

“…Insulin activates lipoprotein lipase and was successfully used in patients with increased glucose levels ( 14 ) or even overt diabetic ketoacidosis, but also in patients without hyperglycemia ( 15 , 16 ). Reduction of triglycerides of about 44% ( 17 ) within the first day was reported in cohorts treated with insulin and 48–72% ( 9 , 13 ) in cohorts with conservative treatment, often including insulin. There is only one non-randomized comparison of insulin therapy with fasting-only, which did not show a more rapid fall in triglycerides ( 18 ).…”

“…Only recently, some non-randomized comparisons of PE with conservative treatment in small cohorts of patients have been published. Some of them showed a greater reduction of triglycerides with PE ( 13 , 17 , 22 ), while others demonstrated only a comparable reduction ( 23 , 24 ), and none of the studies showed a clear clinical benefit of PE ( 13 , 17 , 21 – 23 ). To date, there have been no randomized comparisons between PE and conservative treatments.…”