Futility of plasmapheresis, insulin in normoglycaemic individuals, or heparin in the treatment of hypertriglyceridaemia-induced acute pancreatitis

Abstract

There is a well-established link between the severity of hypertriglyceridaemia and acute pancreatitis and long-term triglyceride-lowering therapies known to prevent episodes of acute pancreatitis. Therefore, it has been assumed, without firm evidence, that rapid lowering of plasma triglycerides would be an effective strategy for reducing the clinical severity of acute pancreatitis and improving health outcomes. Therapies, such as intravenous heparin, intravenous insulin in normoglycaemic individuals (with glucose to prevent hypoglycaemia), and plasmapheresis, continue to be widely used as therapeutic interventions to rapidly reduce serum triglyceride concentration. These therapies are all associated with a risk of adverse reactions, require increased resources, and increase health-care costs. Randomised controlled clinical trials of these therapies have generally shown more rapid reductions in plasma triglycerides than conventional supportive care with the patient made nil by mouth. However, these three therapies alone or in combination, have failed to show effectiveness in improving substantial health benefit outcome measures. While we recognise the theoretical basis for rapidly reducing plasma triglycerides in hypertriglyceridaemia-induced pancreatitis—based on our review of studies using heparin, insulin, plasmapheresis, or a combination of these—these strategies overall do not reduce complications associated with acute pancreatitis or the rapidity of disease resolution. Therefore, we do not advocate the use of triglyceride-lowering therapies at this time, pending more convincing evidence.