Endocrine Abstracts

Case history: A 59-year-old lady with a background of type 2 diabetes, hypercholesterolemia and hypertension presented with a 3-week history of progressively worsening central abdominal pain and vomiting. Her drug history included bezafibrate and atorvastatin on which she was unable to meet her cholesterol and lipid targets and hence were stopped two weeks prior to her admission. The plan had been to start once fortnightly Alirocumab, a PCSK9 inhibitor; which had been delayed due to a lack of availability. Examination revealed xantholasma and abdominal distension with generalised abdominal tenderness.

Investigations: Blood results were initially returned as ‘lipaemic’ and could not be reported. Once the patient had been initiated on a fixed rate insulin infusion, subsequent bloods showed WCC 12.2, Hb 109, Triglycerides 111.80, Cholesterol 32, CRP 48 and amylase 16. The patient’s LFTs were also deranged on admission with an ALT of 83, ALP 289 and a normal bilirubin of 8. The patient underwent a CT abdomen which showed peri-pancreatic inflammatory fat stranding suggestive of acute pancreatitis. In addition it revealed a markedly enlarged liver with appearances consistent with severe hepatic steatosis. In light of this she underwent an abdominal US which showed no evidence of portal or hepatic vein thrombosis and a normal gallbladder without evidence of biliary obstruction.

Results and treatment: She was kept NBM, and jointly managed with the surgeons for acute pancreatitis, secondary to dyslipidaemia. Her hypertriglyceridemia was treated with a fixed rate insulin infusion, dietetic input and the reintroduction of bezafibrate. Restarting atorvastatin was considered, however was precluded by her raised LFTs. Throughout her 9 day admission her triglycerides improved to 13.5 with an HDL of 11.2 and LDL of 0.56. She was successfully initiated on subcutaneous Alirocumab soon after discharge.

Conclusions and points for discussion: The association between dyslipidaemia and acute pancreatitis is well established both as a precipitant and as an epiphenomenon. Dyslipidaemia is commonly secondary to diabetes and obesity, and statins and fibrates are the key pharmacological treatment options. Alirocumab is a monoclonal antibody that binds circulating PCSK9 and blocks its interactions with surface LDLR. It is approved for high risk patients who fail to attain LDL-cholesterol goals despite maximum tolerated medical therapy, including those with a history of pancreatitis. In this case, since the initiation of Alirocumab the patient’s lipid profile has improved significantly and she has not experienced further episodes of pancreatitis.