The cream rises to the top, then creates problems

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 high).
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.