A case series published in the Journal of Pharmacy Practice describes the use of continuous insulin infusions for the treatment of severe hypertriglyceridemia in critically ill patients with COVID-19.
Between March 22 and April 15, 2020, the authors conducted a retrospective chart review of 48 mechanically ventilated COVID-19 patients and identified 5 who were treated with continuous insulin infusion for severe hypertriglyceridemia (triglyceride [TG] values >1000mg/dL). “Insulin promotes the synthesis and activation of [lipoprotein lipase], which hydrolyzes TG into fatty acids and glycerol and facilitates storage of the fatty acids in adipocytes,” the authors explained.
Findings showed that continuous insulin infusion, coupled with standard oral lipid lowering therapies, successfully treated the hypertriglyceridemia. Among 3 of these patients, rapid TG lowering (to <500mg/dL) was observed within 72 hours following insulin infusion initiation. In the other 2 cases, TG levels less than 500mg/dL were reported within 6 and 8 days, respectively.
To mitigate the risk of hypoglycemia, patients were given dextrose infusions and blood glucose checks were conducted every 1 to 2 hours. Only 1 report of hypoglycemia was noted and was corrected quickly, according to the authors. Additionally, none of the patients experienced pancreatitis.
The authors noted several limitations in their report including the inability to establish the most efficacious method of insulin administration (ie, fixed rate vs titration for TG lowering and hyperglycemia), a lack of standardization in blood draws to assess TG levels, as well as the inability to determine the ideal oral agent to use as concomitant therapy. “Use of propofol was another confounder, as duration and discontinuation point of propofol infusions was not uniform amongst cases and may have also contributed to rapid TG lowering,” they added.
Given these unknowns, the authors concluded that further investigation into the use of insulin infusion in the setting of severe hypertriglyceridemia in COVID-19 patients is warranted.
Thomas CM, Vicent M, Moore S, Ali F, Wooten L, Louzon PR. Treatment of severe hypertriglyceridemia with insulin infusions in severe COVID-19: A case series. Journal of Pharmacy Practice. [Published online April 22, 2021.] doi: 10.1177/08971900211010473