Management of Severe Hypertriglyceridemia with Insulin Infusion in COVID-19: Case Series
Rapid onset of severe hypertriglyceridemia was quickly recognized in critical COVID-19 patients. In a recent case series, researchers have reported that insulin infusion therapy rapidly reduces triglyceride levels in COVID 19 positive patients with hypertriglyceridemia. The case series have been published in the Journal of Pharmacy Practice on April 22, 2021.
The severity of hypertriglyceridemia in COVID-19 patients with triglyceride values reaching greater than 1,000 mg/dL increase the risk of pancreatitis. Dr Caitlin M. Thomas and her team conducted a retrospective chart review of 48 critical COVID-19 patients. and identified 5 who were treated with continuous insulin infusion for severe hypertriglyceridemia (triglyceride [TG] values >1000mg/dL).
A 36-year-old Hispanic male with a past medical history (PMH) significant for hypertension and diabetes mellitus type 2 (T2DM) was presented with worsening flu-like symptoms, a 2-day history of diarrhoea, and a close contact that was COVID-19 positive. After 3 days on propofol, his TG level was 1,492 mg/dL. So, propofol was discontinued. However, his TG level peaked at 1,998 mg/dL after 15 hours. On day 6, he was administered with 5.3 units/hr utilizing insulin infusion to achieve normoglycemia. His TG levels subsequently improved after dose escalation. However, on day 32, his TG level peaked for a second time at 1,183 mg/dL, his insulin infusion increased further to 27.7 units/hr, and niacin 500 mg daily was added to his regimen. On day 33, his TG level decreased to 525 mg/dL on insulin 23.9 units/hr and further decreased on day 34. The physicians discontinued niacin and omega-3 polyunsaturated fatty acids due to difficult administration. On day 36, he was again transitioned to subcutaneous long-acting insulin therapy. He was discharged home on day 44 on fenofibrate 200 mg daily as he had no instance of hypoglycemia.
A 44-year-old Hispanic male with a PMH significant for T2DM presented to the ED for a 10-day history of shortness of breath, cough, fever, chills, malaise, loss of taste with a 3-day history of diarrhoea. On day 3, his TG level was 298 mg/dL and, on day 6, his TG level had increased to a peak of 1,349 mg/dL. The physicians then discontinued the propofol and started a titratable insulin drip at 6.2 units/hr to reduce TG levels and achieve normoglycemia. The patient's TG levels were improved and, on day 19, he was transitioned to subcutaneous long-acting insulin therapy.
A 79-year-old Caucasian female with a PMH significant for bronchiectasis, hypothyroidism, and a permanent pacemaker presented to the ED with a 2-week history of dyspnea and intermittent oxygen requirement and a positive COVID-19 test. After intubation, she was administered with propofol and 48 hours after propofol initiation her level peaked at 1,093 mg/dL. The propofol was discontinued and, she was treated with fixed-rate insulin drip at 3units/hr with dextrose 10% in water titrated to maintain euglycemia. The patient experienced 3 hours of hypoglycemia after initiation which was corrected by 100 mL of dextrose 50% in water. By day 5, her TG level had fallen to 248 mg/dL and, the fixed-rate insulin drip was discontinued. Although her TG level continued to decline, the patient lost a detectable pulse and expired on hospital day 6.
A 66-year-old Hispanic male with a PMH of hypertension and hyperlipidemia, not on a statin, presented to the ED with a 5-day history of diarrhoea. His baseline TG level was 312 mg/dL on hospital day 2. On day 5, his TG level increased to 1,042 mg/dL. He was administered with a fixed rate insulin drip at 3 units/hr with dextrose 10% in water titrated to maintain euglycemia. On day 6, his TG level reached 1,436 mg/dL, and omega-3 polyunsaturated fatty acids 4 g twice daily was added to his regimen. However, his TG levels remained unstable. His omega-3 polyunsaturated fatty acids were discontinued, and he was started on fenofibrate 200 mg daily and atorvastatin 40 mg at bedtime. On days 12 and 13, his TG levels continued to decline to 553 mg/dL and 371 mg/dL respectively. On day 23, his level dropped below 200 mg/dL and, the fenofibrate was discontinued. The patient was discharged to a skilled nursing facility (SNF) on day 49 on atorvastatin.
A 72-year-old Caucasian female with a PMH of T2DM, coronary artery disease, hypertension, and hyperlipidemia presented to the ED with 8-day history of left ear pain, shortness of breath, productive cough with green phlegm, nasal congestion, body aches, general weakness, and fever. As her TG levels eventually hit the peak she was administered with insulin drip on an average of 212.1 units/hr. Although her TG level continued to decline, her prognosis remained poor, and the family decided to compassionately withdraw care on hospital day 7.
The authors concluded, "In addition to standard oral lipid lowering therapies, continuous insulin infusion successfully treated severe hypertriglyceridemia in critically ill COVID-19 patients. None of the patients experienced pancreatitis or hypoglycemia necessitating cessation of insulin. "
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