(941) Continuous Insulin Infusion Dosing Strategies for Hypertriglyceridemia-Induced Acute Pancreatitis

Introduction: Continuous insulin infusion therapy (CIIT) at a dose of ≥0.1U/kg/hr triggers the activity of lipoprotein lipase, thereby lowering triglycerides (TG). There is limited data on the optimal initial dosing of insulin infusions and the method of CIIT. Here, we describe initial dosing strategies selected and the relation to efficacy and safety in the management of hypertriglyceridemia-induced acute pancreatitis (HTG-AP).

Methods: This is a retrospective analysis of adults with HTG-AP treated with CIIT from January 2016 to June 2024. The primary outcome was rates of treatment failure (TF), defined as an increase in TG while on CIIT or the need for restarting CIIT after transitioning to oral agents. Secondary outcomes included initial CIIT dose and method (Fixed, Titrate, or DKA), TG levels at transition, readmissions within a year, mortality, and length of stay. Safety outcomes include hypoglycemia ( < 70 mg/dL) and severe hypokalemia (≤2.5 mEq/mL).

Results: Of 81 patients, 63% had a history of diabetes mellitus and alcohol use disorder. The median age was 40 years, 73% were male, and 33% had concomitant DKA. The median TG level at presentation was 1890mg/dL. CIIT was ordered as Fixed (62%), Titrate (20%), and DKA (19%) and the initial dose was ≥0.1U/kg/hr in 63 (78%) with the median maximum dose of 0.1U/kg/hr. TF occurred in 19 (23%) patients overall with 17 having TG increase while on CIIT and 5 needing CIIT restarted. The rate of TF in patients that were started on a suboptimal dose was 37% versus 19% in patients that were started on a dose ≥0.1U/kg/hr. CIIT-Fixed lowered the risk of treatment failure (p=0.044) while CIIT-Titrate increased the risk of TF (p=0.048). The median TG level before transition was 478mg/dL. Both overall and ICU length of stay was a median of 4 days. Safety events included 31 (38%) patients with hypoglycemia and 4 (5%) with severe hypokalemia. There was an increased risk of adverse events for patients with CIIT-Titrate (p=0.048), an initial dose of 0.2U/kg/hr (p=0.007), and treatment failure (p=0.005).

Conclusions: For patients with HTG-AP, CIIT-Titrate was associated with higher rates of treatment failure and adverse events. Further randomized control trials with larger sample sizes should be performed to confirm these findings.