Introduction: The triad of diabetic ketoacidosis, severe hypertriglyceridaemia, and acute pancreatitis is rarely seen. 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. Its use is now controversial. Insulin activates LPL and intravenous therapy is preferred in severe disease for faster lowering of triglycerides. 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]