The Joint Annual Scientific Meetings of the Endocrine Society of Australia and the Society for Reproductive Biology 2018

Diabetic ketoacidosis and hypertriglyceridaemic pancreatitis in undiagnosed type 2 diabetes mellitus - a case report and literature review of the management of severe hypertriglyceridaemic pancreatitis (#282)

Tegan van Gemert 1 , Kay Hau Choy 1 , Zoran Apostoloski 1
  1. The Wollongong Hospital, Wollongong, NSW, Australia

Introduction: The triad of diabetic ketoacidosis, severe hypertriglyceridaemia, and acute pancreatitis is rarely seen.[1] Management of hypertriglyceridemic pancreatitis (HTGP) includes a fat free diet and lipid-lowering pharmacotherapy. Plasmapheresis, insulin and heparin are often considered in severe HTGP to lower triglycerides more rapidly.

Case Report: A 34-year-old man with no past medical history and BMI 37.6kg/m2, presents drowsy, febrile and tachycardic. Investigations reveal a non-anion gap metabolic acidosis (pH 7.26), glucose 81mmol/L, ketones 5.6mmol/L, lipase 3590U/L and triglycerides 91mmol/L. HbA1c was 14.1% (131mmol/mol), C-peptide 0.93nmol/L, Anti-GAD <5U/ml and IA2-antibodies <8U/mL. He was diagnosed with Type 2 Diabetes Mellitus. Intravenous fluids and insulin were commenced. Given the marked hypertriglyceridemia and severity of pancreatitis, plasmapheresis was implemented. Within 12 hours triglycerides were 15.3mmol/L. He had a long, complicated admission including multiple pancreatic necrosectomies. On discharge he had good glycaemic control on Metformin alone and having lost 37kg. Metformin was ceased four months later. His HbA1c was 5.3% (34mmol/mol) and fasting triglycerides 1.4mmol/L.

Discussion: There is a lack of randomised trials on HTGP management. In severe disease, heparin, insulin and plasmapheresis are often considered. Heparin only transiently increases lipoprotein lipase (LPL) to reduce triglycerides followed by depletion and deficiency of LPL.[2] Its use is now controversial. Insulin activates LPL and intravenous therapy is preferred in severe disease for faster lowering of triglycerides.[3] Plasmapheresis rapidly reduces triglyceride levels but mortality and morbidity benefits remain unclear.[4,5] Timing of plasmapheresis appears crucial with early implementation required for maximal benefit.[4-6] Case series comparing insulin to plasmapheresis demonstrate greater reductions in triglycerides with plasmapheresis but longer hospital stay and no mortality difference.[7,8] Although there are no definitive guidelines, insulin, especially in diabetics, is often favoured for simplicity and cost.  However, some authors suggest considering plasmapheresis in very severe disease or failure to respond to other therapy within 24-48 hours.[9,10]

  1. Nair, S., Yadav, D., Pitchumoni, C. Association of diabetic ketoacidosis and acute pancreatitis: observations in 100 consecutive episodes of DKA. Am J Gastroenterol. 2000;95(10):2795-2800
  2. Nasstrom, B., Olivecrona, G., Olivecrona T., et al. Lipoprotein lipase during continuous heparin infusion: tissue stores become partially depleted. J Lab Clin Med. 2001;138:206-213
  3. Al-Humoud, H., Alhumoud, E., Al-Hilali, N. Therapeutic plasma exchange for acute hyperlipidemic pancreatitis: a case series. Ther Apher Dial. 2008;12:202-204
  4. Kyriakidis, A., Karydakis, P., Neofytou, N., et al. Plasmapheresis in the management of acute severe hyperlipidemic pancreatitis: report of 5 cases. Pancreatology. 2005;5:201-204
  5. Chen, J., Yeh, J., Lai, H., et al. Therapeutic plasma exchange in patients with hypelipidemic pancreatitis. World J Gastroenterol. 2004;10:2272-2274
  6. Lennertz, A., Parhofer, K., Samtleben, W., et al. Therapeutic plasma exchange in patients with chylomicronemia syndrome complicated by acute pancreatitis. Ther Apher. 1999;3:227-233
  7. Afari, M., Shafqat, H., Shafi, M., et al. Hypertriglyceridemia-Induced Pancreatitis: A decade of Experience in a Community-Based Teaching Hospital. R I Med Journ. 2015;98(12):40-43
  8. Chen, J., Yeh, J., Lai, H., et al. Therapeutic plasma exchange in patients with hyperlipidemic pancreatitis. World J Gastroenterol. 2004;10:2272-2274
  9. Scherer, J., Singh, V., Pitchumoni, C., et al. Issues in Hypertriglyceridemic Pancreatitis – An Update. J Clin Gastroenterol. 2014;48(3):195-203
  10. Ewald, N. & Hans-Ulrich, K. Treatment options for severe hypertriglyceridemia (SHTG): the role of apheresis. Clin Research in Cardiol. 2012;7(1):31-35