I recently encountered three men with poorly controlled type 2 diabetes
complicated by severe hypertriglyceridemia and I was faced with some difficult
decisions to make.
- Case 1: 43-year-old with type 2 diabetes for about five years; BMI of
32, HbA1c 10.2 %and triglyceride level was 7,254 mg/dL (yes, it was that
- Case 2: 37-year-old with type 2 diabetes for seven years. BMI of 29,
HbA1c 8.6% and triglyceride level of 3,682 mg/dL .
- Case 3: 38-year-old with type 2 diabetes for only three years. BMI of
35, HbA1c 9.6% and triglyceride level of 4,943 mg/dL .
These men shared several other clinical characteristics. Each had a
positive family history of type 2 diabetes; each had been treated with oral
agents only until quite recently when either prandial insulin (two patients) or
glargine insulin at night had been started. Each patient was asymptomatic and
only one had a few eruptive xanthomas.
My problems started when I looked at their lab data, which were five to
10 days old when they came to the clinic. Not only was their triglyceride
significantly high, but many other analyses in the printout were abnormal and
essentially meaningless. Two of them had hyponatremia with serum sodium of 125
mEq/L and 126 mEq/L, and one patient had a reported estimated GFR of 1,273
I did not make this up. The GFR was reported as >60 in one and 251 in
the third. The total cholesterol, LDL, and HDL were also meaningless.
That they were reported at all with these obvious measurement errors and
without any effort to notify the requesting physician of critical values is a
major concern. In desperation I called the first of the three labs where these
measurements had been made and reported. I was advised that none of the lab
results from that report could be trusted. Really!! A fasting specimen should
be collected and ultra-centrifuged before any measurements were made and the
measurements should be made with ion-specific electrode (ISE) methods.
Now the problem is what to do with these asymptomatic patients while
waiting for correct laboratory values. After discussing the clinical situation
with each patient and making changes to the management of their uncontrolled
diabetes I collected a blood sample from each and had it spun down in the
clinic centrifuge. Even without letting it sit in the refrigerator overnight as
we were taught during residency, it was abundantly evident (I was about to say
abundantly clear but it was abundantly cloudy) that each of them had very
lipemic serum. I am kicking myself for not doing a fundoscopic exam to look for
lipemia retinalis, but I was far more concerned about lipid management.
There are options for less severe increases in triglyceride which can be
classified as: Normal <150 mg/dL; Borderline 150 mg/dL to 199 mg/dL; High
200 mg/dL to 499 mg/dL; and Very high >500mg/dL.
Diet counseling is essential, but values >200 should be treated with
fibric acid derivatives, niacin, or omega-3 fatty acids. With higher
triglyceride levels, consideration should be given to adding a statin or
increasing the dose of statin if that is already being used.
Aggressive measures including withholding food, maintaining hydration
with IV fluids, and sometimes plasmaphoresis are called for in the setting of
acute pancreatitis or unstable cardiac disease, but my patients were
asymptomatic and such approaches did not seem justified. At the same time one
has to be cognizant that an acute clinical problem could arise at any time.
Each patient was instructed to limit his food intake (unlikely to
happen) and maintain more than adequate hydration. One patient already on a
statin had his dose increased and I added omega-3 fatty acid therapy. For the
other two I recommended extended release niacin and omega-3 fatty acid.
To date, my patients have been doing remarkably well with glycemic
control on their minimalist diets and that of itself is an important lesson
with long-term benefit for them. They remain symptom free from their
hypertriglyceridemia but I am not sure how often it should be repeated given
the complexity of the processing.
As with each of these blogs in which I report unusual/extreme
abnormalities, comment and advice from readers will be a big help.