SUN-228 - Fasting Is (More) Furious: Management of Asymptomatic Severe Hypertriglyceridemia with Diet

Background
Severe hypertriglyceridemia (HTG) can be defined as a triglyceride (TG) level >1000 mg/dL. HTG pancreatitis is often treated with intravenous (IV) insulin, but there is little data on treatment recommendations for asymptomatic severe HTG other than fibrates. We present a case of asymptomatic severe HTG managed with a combination of diet and insulin.

Case
A 39-year-old man with T2DM and pancreatitis was admitted for DKA and was found to have a TG level >8000 mg/dL ( < 149 mg/dL). Home medications included insulin, though the patient reported noncompliance. A1c was 12.8% ( < 5.6%). Total cholesterol was 1318 mg/dL (125-199 mg/dL), HDL 4 mg/dL (>40 mg/dL), and LDL 42 mg/dL ( < 99 mg/dL). Lipase was 58 U/L (13-60 U/L) with no abdominal pain, excluding pancreatitis. IV insulin was started and the diet was changed to nothing by mouth (NPO). TG level was 5723 mg/dL after 4 days. He was then switched to a consistent carbohydrate low-fat diet and subcutaneous (SQ) insulin for 2 days, resulting in a TG level of 3477 mg/dL. Due to the slow decrease of TG, IV insulin and NPO status was restarted with TG levels decreasing to 1683 mg/dL over 4 days. A diet was then restarted a day after per patient preference, but TG increased again to 1887 mg/dL, so the patient was returned to NPO with improvement. After TG reached 983 mg/dL, the patient was discharged on SQ insulin, fenofibrate, atorvastatin, and omega-3.

Discussion
There is less information available for management of asymptomatic severe HTG without pancreatitis compared to HTG with pancreatitis. A study comparing IV insulin to conservative management (i.e. SQ insulin in patients with diabetes and fasting alone in patients without diabetes) in patients with HTG-associated acute pancreatitis showed that IV insulin was not superior to SQ insulin or fasting. Another study reported that IV insulin with fasting was more effective than IV insulin alone in decreasing TG levels in patients with severe HTG without pancreatitis. In this case, the patient did not have pancreatitis, but TG levels decreased slower when on a diet with SQ insulin than they did when NPO and even increased with IV insulin while on a diet. This patient case has implications in the management of asymptomatic HTG as severe levels even beyond typical levels can likely be managed out of the ICU without needing IV insulin.

Conclusion
This case demonstrates the varying effects of diet, IV, and SQ insulin, and that fasting potentially may be the most cost effective and clinically significant method of improving TG levels in an asymptomatic patient. Potential avoidance of ICU stays and hospital admissions could be considered in a patient who is able to be compliant with fasting only in asymptomatic severe HTG.

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