S3487 Bile Acid Sequestrant-Induced Hypertriglyceridemia Leading to Acute Pancreatitis: A Case Report

Introduction: Bile acid sequestrants are effective in managing bile acid malabsorption-associated diarrhea, which is common in patients with inflammatory bowel disease (IBD), particularly in those with ileal dysfunction or resection. Bile acid malabsorption occurs due to impaired reabsorption of bile acids in the ileum, leading to increased bile acids in the colon, which stimulates water and electrolyte secretion, causing diarrhea. Although effective for gastrointestinal symptoms, they can affect lipid metabolism and pre-dispose one to consequences of hypertriglyceridemia. Case Description/Methods: A 58-year-old White man with a history of ileocolonic Crohn’s disease status post-surgical resection on ustekinumab was prescribed colesevelam for bile acid diarrhea which provided subsequent relief. Unfortunately, he was later hospitalized for acute abdominal pain and found to have acute pancreatitis due to severe hypertriglyceridemia (TG >4000 mg/dL). On admission, imaging demonstrated acute pancreatitis without evidence of cholelithiasis or common bile duct dilation. He did not drink alcohol and had no other identifiable causes for the acute pancreatitis other than the hypertriglyceridemia. He was subsequently discharged home after treatment of the acute pancreatitis. Discontinuation of colesevelam resulted in the return of his diarrhea. Discussion: Bile acid sequestrants can significantly impact lipid metabolism, lowering low-density lipoprotein cholesterol but also potentially causing severe hypertriglyceridemia. This occurs through increased hepatic bile acid synthesis and activation of lipogenesis. Endocrine and cardiology guidelines advise against BAS use in patients with elevated triglycerides, particularly ≥300 mg/dL, due to the risk of acute pancreatitis. Despite this, routine triglyceride screening is not standard before initiating bile acid sequestrant therapy for bile acid diarrhea. Given the prevalence of hypertriglyceridemia and reports of pancreatitis likely triggered by bile acid sequestrants, we recommend triglyceride screening in all patients with bile acid diarrhea prior to initiating bile acid sequestrant therapy.