Treating hypertriglyceridemia

In their review of hypertriglyceridemia, George Yuan and colleagues advocate “hemodynamic stabilization, cessation of all oral intake, placement of a nasogastric tube and control of metabolic disturbances” to treat triglyceride-related acute pancreatitis.¹ The authors are skeptical about the use of plasmapheresis because it provides only a transient benefit.

We use a different treatment method (heparin and insulin infusions to stimulate lipoprotein lipase activity and therefore reduce serum triglyceride levels²)as the first-line therapy in our hospital, as described in the following case. A 29-year-old man with an uneventful medical history was admitted to hospital because of severe abdominal pain with a clinical diagnosis of acute pancreatitis. The fasting triglyceride level was nearly 8000 mg/dL at admission. In addition to standard therapy for pancreatitis, an insulin infusion was started at 4 IU/h with glucose substitution as necessary. Low-molecular-weight heparin was also administered. Within 5 days the patient was asymptomatic and his triglyceride level had decreased to 450 mg/dL. His lipemic serum had a milky appearance at admission and a nearly normal clear appearance on day 5 (Figure 1). Case series and case reports describing the treatment of pancreatitis with heparin and insulin have been published,^3–5 but the efficacy of this treatment method has not yet been well established, presumably because of the lack of controlled trials.

Figure 1: Serum of a patient with triglyceride-related acute pancreatitis. Left: Lipemic serum before treatment with insulin and heparin. Right: Clear serum after 5 days of therapy.