Title : Insulin resistance spawns hypertriglyceridemia-induced acute pancreatitis and diabetic ketoacidosis: Unboxing a new metabolic crisis
Abstract:
Introduction: Insulin resistance (IR) means defective insulin stimulated glucose uptake accompanied by impaired insulin induced suppression of hepatic glucose output. Hypertriglyceridemia (HTG) constitutes a critical component of metabolic syndrome, which includes obesity, HTG, low high density lipoprotein, hypertension and type 2 diabetes. Here we present two cases of severe HTG in poorly controlled T2DM provoking acute pancreatitis and diabetic ketoacidosis (DKA).
Description: A 48 year old female presented with a 3 day epiga stric pain. She had a history of T2DM, hypertension and obstructive sleep apnea, no family history or other risk factors. Triglyceride was 3841 mg/dL and HbA1c 10.1%. A 32 year old male with T2DM came with 2 day abdominal pain. He was hospitalized 9 months ago for Hypertriglyceridemia induced acute pancreatitis (HTGAP) with triglyceride of 650mg/dL. He was non compliant. His parents both had T2DM at their 40s. He is a non smoker and non drinker. His triglyceride was 5359 mg/dL with HbA1c of 12%. Both patien ts had elevated lipase, anion gap and c peptide with abdomen 2 computed tomography (CT) showing pancreatitis and hepatic steatosis. Both were admitted to computed tomography (CT) showing pancreatitis and hepatic steatosis. Both were admitted to the intensive care unit receiving continuous insulin and Lactated Ringer’s solution infusion. The the intensive care unit receiving continuous insulin and Lactated Ringer’s solution infusion. The DKAs wDKAs were resolved in 24 hours and triglycerides gradually decreased to less than 1000 mg/dL ere resolved in 24 hours and triglycerides gradually decreased to less than 1000 mg/dL on days 5 to 6. Both were discharged with Fenofibrate, Atorvastatin and insulin.on days 5 to 6. Both were discharged with Fenofibrate, Atorvastatin and insulin.
Discussion: This scenario represents an acute metabolic crisis of lipid and glucose. IR This scenario represents an acute metabolic crisis of lipid and glucose. IR and and its consequent overits consequent over--activated lipolysis create a twoactivated lipolysis create a two--way feedback between the white adipose way feedback between the white adipose tissue and liver, which damages pancreases with pancreatic selftissue and liver, which damages pancreases with pancreatic self--hydrolysis leading to HTGAP. hydrolysis leading to HTGAP. HTGAP further triggers counterHTGAP further triggers counter--regulatory hormone to worsen hyperglregulatory hormone to worsen hyperglycemia and lipolysis, ycemia and lipolysis, ultimately causing downward spiral of HTGAPultimately causing downward spiral of HTGAP--DKA (Figure). Acute management involves fluid DKA (Figure). Acute management involves fluid resuscitation, insulin infusion, and nutrition management and complications prevention. Chronic resuscitation, insulin infusion, and nutrition management and complications prevention. Chronic management includes nonmanagement includes non--pharmacological measurespharmacological measures and medications including Fibrates, Statin, and medications including Fibrates, Statin, OmegaOmega--3 fatty acids, Metformin and Sodium3 fatty acids, Metformin and Sodium--glucose cotransporterglucose cotransporter--2 inhibitors. Further 2 inhibitors. Further investigation involves developing clinically applicable assessment of lipolysis, pancreatic investigation involves developing clinically applicable assessment of lipolysis, pancreatic functions and stratified functionfunctions and stratified functional and pathological diagnosis for IRal and pathological diagnosis for IR-- lipolysis cycle.lipolysis cycle.
Keywords:
type 2 diabetes mellitus; insulin resistance; hypertriglyceridemia; : type 2 diabetes mellitus; insulin resistance; hypertriglyceridemia; hypertriglyceridemiahypertriglyceridemia--induced acute pancreatitis; diabetic ketoacidosis; lipolysis induced acute pancreatitis; diabetic ketoacidosis; lipolysis
