Aim. Hypertriglyceridemia (HTG) causes 1 to 4% of all cases of acute pancreatitis and is the third most common cause after alcohol and gallstones. HTG is considered a risk factor for acute pancreatitis when levels are above 11.2 mmol/l (severe HTG). Mild HTG is a common finding in pancreatitis of other etiology. The rapid decrease of triglycerid levels is a treatment priority with an initial goal of <5,6 mmol/l. Along with conventional therapy of acute pancreatitis, several treatment modalities have been described in literature to decrease triglyceride levels rapidly, including plasmapheresis, insulin and heparin. To date no randomized trials have compared the efficacy of plasmapheresis with that of insulin and heparin, and there are no definitive guidelines for the treatment of HTG-induced acute pancreatitis. Insulin decreases serum triglycerid levels by enhancing lipoprotein lipase activity, an enzyme that accelerates chylomicrone and VLDL metabolism to glycerol and fatty free acids. It also inhibits hormone-sensitive lipase in adipocytes, the key enzyme for breaking down adipocyte triglycerides and releasing free fatty acids into the circulation. Our aim is to report on nine patients with HTG-induced acute pancreatitis that were successfully treated with continuous insulin infusion.
Methods. In a two-year period, nine patients were admitted to the medical ICU with a diagnosis of HTG-induced acute pancreatitis. Along with standard therapy, they were treated with a continuous infusion of 5% dextrose and insulin in an attempt to lower triglyceride levels. The initial dose of insulin was 6IU/h, and the dose was adjusted to maintain blood sugar levels between 6.6 and 8.8 mmol/l. Triglyceride levels were assessed on admission, and on the second and fourth days of therapy. Therapy lasted for four days.
Results. All study subjects were male, and their mean age was 44.7 years (range from 29 to 60 years). The mean triglyceride level at admission was 56.26±34.3 mmol/l (range from 16.8 to 122 mmol/l). 89% of patients had elevated levels of glucose (above 10 mmol/l) and 50% had a history of alcohol consumption. The mean APACHE II score was 11, Ranson score 5 and Balthazar score 7. In all patients a significant decrease in triglyceride levels were achieved on day four and in 89% of them they were below 5.6 mmol/l. The only patient whose values on day four were above 5.6 mmol/l had triglyceride levels of 122 mmol/l at admission. One patient had severe respiratory insufficiency due to acute respiratory distress syndrome (ARDS). He was mechanically ventilated for four days and afterwards completely recovered. Complications of therapy were not encountered and none of the patients died. All patients recovered completely, without complications, and no need for other interventions. The follow up period lasted for two years with no recurrences of acute pancreatitis.
Conclusion. Our study showed that continuous insulin infusion rapidly decreases triglyceride levels in the early phase of HTG-induced acute pancreatitis. The decrease in triglyceride levels was accompanied by clinical improvement, even in patients with severe acute pancreatitis and organ dysfunction. We found this therapy extremely efficient, safe, as well as simple to administer and monitor.
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