Hypertriglyceridemia — A Sign of “A Diabetic Want 2 B”.

On March 4, 2020 I saw a man with triglycerides (TGs) of 4,480 mg/dl. His values are below.

His vitamin D level was 13 and his CRP 2.5 when measured on March 2, 2020

This case raises several important issues.

1.Fasting TGs >1000 mg/dl are a medical emergency because the patient can develop life-threatening, hemorrhagic pancreatitis. I have had one patient die, and one get an abdominal compartment syndrome requiring leaving her abdomen open for a week. Consequently, when we get a report of TGs > 1000 mg/dl, we see the patient that day, if possible. If we cannot see the patient that day, we start them on fenofibrate 145 mg daily and on concentrated prescription fish oil such as Vascepa or Lovaza, 2 gms twice daily. This is done sight unseen, over the phone. Over-the-counter fish oil does not cut it because it has ❤00 mg of the active agents, eicosapentaenoic acid or EPA, in the 1000 mg pill.

2. Most of these new onset, extremely high TG patients have either diabetes or “borderline diabetes”. Insulin drives free fatty acids into the fat cell so if there is not enough insulin, free fatty acids exit the fat cell and the liver picks them up to make TGs. This man’s A1C was 13.8 mg/dl. The trick to treating these patients is to treat both the diabetes and the hyperTGs simultaneously and fast. Interestingly, such terrible TG levels can occur in patients with only “borderline diabetes” because it takes more insulin to regulate fat than glucose. Increased TGs are a sign of a “diabetic want-2-B”. 

3. His vitamin D was low at 13 and his TSH was low at 0.63 when measured in March. These may be spuriously low values due to the high TGs that displace volume normally occupied by serum/plasma. When a fixed volume of lipemic plasma/serum is measured, the resulting analyte concentration may be artifactually reduced. This inherent error in lipemic specimens can be avoided by airfuge ultra-centrifugation to clear lipemia in serum/plasma. Because this result was obtained from another laboratory, it is unknown if the specimen was cleared of lipemia prior to analysis. Increased TGs may also bind the fat soluble Vitamin D and potentially interfere with its measurement. However, I doubt this was an issue because the TSH was low as well. We usually wait until the TGs are corrected and repeat these measurements