What is the role of Insulin (recombinant human insulin) in the management of Acute Pancreatitis?

From the Guidelines

Insulin therapy should be used in acute pancreatitis to control hyperglycemia, as it can help reduce the risk of complications and improve outcomes. According to the ESPEN guidelines on nutrition in acute pancreatitis 1, hyperglycemia is a common issue in patients with acute pancreatitis due to impaired insulin release and increased glucose administration through intravenous nutrition.

Key Considerations

• The guidelines suggest that intravenous glucose administration can lead to hyperglycemia, which can be partly corrected with exogenous insulin administration 1.
• However, the use of supplemental insulin is primarily beneficial for monitoring blood glucose levels, rather than providing any additional benefits to the patient 1.
• Enteral glucose perfusion into the jejunum is a weaker stimulus for exocrine pancreatic secretory responses compared to intragastric or intraduodenal administration 1.

Recommendations

• For patients with hyperglycemia, insulin therapy should be initiated to maintain blood glucose levels within a target range, typically between 140-180 mg/dL.
• The choice of insulin regimen, such as basal-bolus or insulin infusion, depends on the severity of hyperglycemia and the patient's clinical condition.
• Close monitoring of blood glucose levels is essential to avoid hypoglycemia, particularly in critically ill patients.

Rationale

• Controlling blood glucose levels can help reduce the risk of infections and improve outcomes in patients with acute pancreatitis.
• Insulin resistance and impaired insulin production are common in acute pancreatitis, making insulin therapy necessary to achieve adequate glucose control 1.
• High-dose dextrose solutions used for nutrition support can exacerbate hyperglycemia, making insulin therapy even more crucial in these patients.

From the Research

Use of Insulin in Acute Pancreatitis

• The use of insulin in acute pancreatitis is a topic of interest, with some studies suggesting its effectiveness in lowering triglyceride concentrations in hypertriglyceridemia-associated acute pancreatitis (HAAP) 2, 3.
• However, a study published in 2020 found that intravenous insulin did not result in a more rapid fall in triglyceride concentrations compared to conservative treatment in patients with HAAP 2.
• Another study published in 2015 reported that insulin administration was effective in reducing triglyceride levels in patients with HAAP, with serum triglyceride levels decreasing to < 500 mg/dl within 2-3 days 3.
• In terms of stress hyperglycemia in acute pancreatitis, a study published in 2025 suggested that insulin therapy should not be undertaken if the blood glucose level does not exceed 10 mmol/L, especially during the first 3 days of hospitalization 4.
• The impact of serum glucose levels on outcomes in acute pancreatitis has also been studied, with one study finding that on-admission hyperglycemia predicts a higher inflammatory response, and the presence of hyperglycemia during hospitalization is associated with a more severe disease course 5.
• Additionally, a study published in 2023 found that both hyperglycemia and hypoglycemia increase the length of hospital stay in patients with acute pancreatitis, and that blood glucose control in a reasonable range of 68-104 mg/dl is required 6.

Hypertriglyceridemia-Associated Acute Pancreatitis

• Hypertriglyceridemia is implicated in ~5% of cases of acute pancreatitis, and it is assumed that intravenous insulin is effective in lowering triglyceride concentrations in HAAP 2.
• A study published in 2020 found that fasting and intravenous fluids were effective in lowering triglyceride concentrations rapidly, with no further contribution from insulin 2.
• Another study published in 2015 reported that insulin-stimulated lipoprotein lipase is known to decrease serum triglyceride levels, and that insulin administration was effective in reducing triglyceride levels in patients with HAAP 3.

Stress Hyperglycemia

• Stress hyperglycemia is a transient increase in glucose during a critical illness, and its possible mechanism is related to abnormal glucose metabolism and insulin resistance due to the increased release of counterregulatory hormones and cytokines 4.
• A study published in 2025 suggested that stress hyperglycemia may be a significant independent risk factor for poor clinical outcomes and prognosis in patients with acute pancreatitis 4.
• The study also suggested that insulin therapy should not be undertaken if the blood glucose level does not exceed 10 mmol/L, especially during the first 3 days of hospitalization 4.