I once heard an endocrinologist comment, “There is no bad insulin “. A true statement indeed if there ever was one. We are familiar with the wonders of continuous insulin infusions for treating DKA, hyperosmolar states, stress hyperglycemia in the critically ill, and hyperglycemia related to steroids. There is another very important use for continuous insulin infusions in the hospitalized patient. Hypertriglyceridemia is also effectively treated with continuous insulin infusions, particularly in cases of triglycerides at around or greater than 1000 mg/dL. Patients can potentially be developing severe pain and symptoms of acute pancreatitis causing further damage to acinar pancreatic cells at this value or higher.
I like to make the analogy that continuous insulin infusions are the “poor man’s” treatment plan. Insulin is a high risk medication regardless by what method it is administered. However, a continuous insulin infusion alone is far less risky than a continuous insulin infusion and concurrent heparin infusion. Both help to reduce triglycerides by activating lipoprotein lipase (LPL) activity, which in turn accelerates clearance and subsequent falls in triglycerides. The clearance of triglycerides by plasmapheresis can be very effective in reducing triglycerides quickly and reducing the pain in acute pancreatitis. However, plasmapheresis carries multiple additional risks of central line infection from placement of a hemodialysis catheter. The cost and length of stay for patients can be extended due this more invasive treatment.
I have seen continuous insulin infusions used safely and effectively at my organization. Keep in mind that not all patients with significant triglyceride elevations will present with DKA or even have diabetes. For those patients with DKA that resolves before the triglycerides fall or DKA is absent, a higher source of dextrose (D10W) may be needed to keep blood glucose values high enough in order to continue the insulin infusion. The goal is to reduce the triglycerides to less than 500 mg/dL, reduce pain, and then begin a transition plan from the insulin infusion.