Treatment of Hypertriglyceridemia-Induced Acute Pancreatitis With Insulin, Heparin, and Gemfibrozil: A Case Series

Abstract

Hypertriglyceridemia is the third most common worldwide cause of acute pancreatitis. Resolving the underlying etiology is imperative for optimal management. This is especially true with regard to hypertriglyceridemia, as this etiology may cause more severe acute pancreatitis and worse symptoms than other causes of the disease. Many pharmacological treatment options for hypertriglyceridemia-induced acute pancreatitis (HTGP) have been proposed; however, the safety and efficacy for specific treatment regimens remain nebulous. At our institution, 6 patients, whose average Ranson criteria score were 5 and presenting triglyceride concentrations were 3501 mg/dL, were managed with a continuous infusion of insulin, subcutaneous heparin, and oral gemfibrozil for HTGP. Maximum insulin infusion rates ranged from 0.8 to 20.9 U/h. Half of the patients received nongemfibrozil cholesterol medication. Five patients experienced a resolution of HTGP (median day 3). The only adverse drug event was hypoglycemia in a single patient. Combination therapy with heparin, insulin, and gemfibrozil is safe and efficacious in quickly lowering serum triglyceride concentrations in HTGP. This combination warrants further study.

Treatment of Hypertriglyceridemia with Aggressive Continuous Intravenous Insulin

“…Patients with severe hypertriglyceridemia (HT), defined as a triglyceride level greater than 1000 mg/dL, are at risk for development of acute pancreatitis, premature atherosclerosis, or cardiovascular disease (1,2). HT is reported to cause 1 to 7% of acute pancreatitis events in individuals of all ages, secondary only to alcohol and gallstones (3)(4)(5)(6). It is hypothesized that HT causes pancreatitis by damaging acinar cells and microvascular membranes from elevated free fatty acid and lysolecithin formation in the pancreatic bed (7).…”

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

“…HTG is an important cause of acute AP. 1 HTGP may cause more severe AP and worse symptoms. 2 Thus, early clinical recognition of HTGP is important to provide appropriate therapy.…”

“…Hypertriglyceridaemia (HTG) is the third most common worldwide cause of AP after gallstones and alcohol. 1 Although the clinical presentation of hypertriglyceridaemic pancreatitis (HTGP) is usually similar to other forms of AP, it may cause more severe AP and worse symptoms. 2 HTG is considered a significant risk for AP when its levels are >11.3 mmol/L (1000.9 mg/dL).…”

Heparin beyond anti-coagulation

“…Of note, LMWH strikingly diminished pancreatic necrosis development to 3.1% from 22.6% of the patients, which represents a phenotype of organ damages resulting from TNF-α. Besides, heparin in synergy with insulin is particularly efficacious on managing hypertriglyceridemia-induced AP, since heparin binds with lipoprotein lipase (LPL) and releases LPL from tissues into the blood to catabolize circulating triglycerides [ 34 , 35 ].…”