MON-279 - Hypertriglyceridemia-Induced Pancreatitis Requiring Plasmapheresis Due to Refractory Hypoglycemia on Insulin Infusion

Introduction:
Acute pancreatitis is typically caused by gallstones and alcohol. Hypertriglyceridemia can be a cause of pancreatitis in 1-7% of all cases. The risk of acute pancreatitis increases when triglycerides are greater than 500 mg/dL but most often seen when triglycerides are above 1000 mg/dL. Treatment typically involves intravenous fluid resuscitation and analgesia. In severe hypertriglyceridemia, insulin infusions are more often used, with plasmapheresis typically reserved for patients with consistently elevated triglycerides above 1000 mg/dL in the first 48 hours despite medical management.

Case Description:
A 40-year-old male with history of heavy alcohol use presented for abdominal pain found to have multiple severe metabolic derangements requiring intensive care unit admission. Laboratory evaluation revealed sodium of 108 mmol/L (135-145), bicarbonate of 12 mmol/L (21-32), anion gap of 26, and glucose of 712 mg/dL (70-99), lipase 1319 U/L (15-77), triglycerides 1762 mg/dL ( < 150), beta-hydroxybutyrate 0.8 mmol/L (0-0.3), glycohemoglobin of 5.8%, and no detected blood alcohol level. Arterial blood gas showed pH of 7.20. Computed tomography of the abdomen and pelvis showed acute interstitial edematous pancreatitis with small to moderate acute peripancreatic fluid. An insulin infusion was started for diabetic ketoacidosis and severe hypertriglyceridemia. A dextrose infusion was started shortly after due to hypoglycemia. Triglycerides improved to 982 mg/dL; however, the patient was persistently hypoglycemic despite the use of a dextrose 20% infusion and the lowest fixed dose of insulin drip at 0.03 units/kg/h. Hematology was consulted and initiated plasmapheresis. After one session of plasmapheresis, triglycerides improved to 310 mg/dL and further improved to 246 mg/dL prior to discharge. The patient was discharged on fenofibrate 54 mg daily and subcutaneous insulin.

Conclusion/

Discussion:

This case highlights the role of plasmapheresis in severe hypertriglyceridemia when insulin infusion therapy is limited due to persistent hypoglycemia despite aggressive dextrose support. While fluid repletion and fixed dose insulin infusion is generally preferred as the standard of care, its use may be limited by metabolic complications, as seen in this patient. Although plasmapheresis can rapidly lower triglyceride levels by greater than 50% after a single session, current evidence has not shown clear superiority in clinical outcomes over conservative or insulin-based management, and routine first-line use is not recommended. In carefully selected patients in whom standard therapy cannot be continued, plasmapheresis may serve as an effective rescue strategy. Additional studies are needed to define the patients most likely to benefit and the optimal threshold for escalation.

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