Endocrine Abstracts

Hypertriglyceridemia is a rare cause of acute pancreatitis occurring 1-35% of patients. Management of hypertriglyceridemia includes the use of intravenous insulin, however, requires close monitoring of capillary blood glucose every 1-2 hours and might warrant ICU admission, increasing the financial burden of patients. This case report explores the use of subcutaneous long-acting insulin, instead of intravenous insulin, on top of conventional therapy and Levothyroxine supplementation in a 47 year-old hypothyroid and diabetic female newly-diagnosed with severe hypertriglyceridemia. The patient initially came in for a 2-day history of new onset epigastric pain radiating to the back, aggravated by eating. Due to persistence, sought consult in the emergency room. Vital signs were stable. Workup done showed microcytic hypochromic anemia, leukocytosis with neutrophilic predominance (Hemoglobin 10.1 g/dl, Hematocrit 28.3%, WBC 11840 mm³, 84% neutrophils, 10% leukocytes, Platelets 266,000 mm³, MCV 58 fL, MCHC 36%), elevated CRP 48 mg/l, elevated ESR 24 mm/hr, elevated TSH 32.556 uIU/ml, low FT4 and FT3 of 0.76 ng/dl and 1.14 pg/ml respectively, normal transaminases (ALT 11 U/l, AST 12 U/l), normal bilirubin (total 0.2 mg/dl, direct 0.02 mg/dl, indirect 0.18 mg/dl), normal alkaline phosphatase (82 U/l), albumin (3.5 g/dl), elevated HbA1c 9.5%, normal ionized calcium (1.11 mmol/l), creatinine 0.74 mg/dl, BUN 6 mg/dl, potassium 3.6mEq/l, chloride (99 mEq/l), low sodium (131.4mEq/l), bicarbonate (19.9 mEq/l). Lipase was 4.1x elevated (222 U/l). Triglycerides and VLDL were elevated at 5177 mg/dl and 1035.4 mg/dl respectively. Capillary blood glucose was 237. ABG done showed a pH 7.42, pCO2 33, HCO3 21.4 O2 sat 96%, and a lactate of 1. BISAP score was 0. She was initially hydrated with 125 ml/hr of D5NSS, given Hyoscine N-Butylbromide for pain control, and placed on NPO. Since the patient had limited funds, the use of subcutaneous long acting insulin of approximately 0.2units/kg/day was given (15 units Glargine). The gastroenterologist also cleared the patient to be started on Levothyroxine 100 mg once daily (~1.76 mg/kg/d) and Fenofibrate 160 mg once daily. Serial monitoring of triglycerides was done noting a decreased trend of 1634 mg/dl on the 2nd day, 989 mg/dl on the 3st day, and 651 mg/dl on the 5th day. VLDL was also decreasing to 326.8 mg/dl on the 2nd day, 197.8 mg/dl on the 3st day, and 130.2 mg/dl on the 5th day. The patient was sent home well. Severe hypertriglyceridemia should still be considered in all patients with acute pancreatitis. Subcutaneous instead of intravenous insulin can be considered as a treatment modality in patients with hypertriglyceridemia-induced pancreatitis on top of conventional therapy.