Extreme hypertriglyceridemia can cause acute pancreatitis. It can also wreak havoc on the management of hospitalized patients by interfering with their lab tests. Management is a challenge, as it often responds inadequately to conventional measures. This article discusses two under appreciated (and off label) tricks of the trade: insulin infusion and heparin infusion. These treatments rapidly clear triglycerides and work about as well as plasmapheresis. They work by facilitating lipoprotein lipase. In the case of insulin, hark back to basic biochem and note an important distinction which is an apparent paradox: while insulin facilitates the action of lipoprotein lipase to clear triglycerides from the circulation it also inhibits hormone sensitive lipase in adipose tissue, the rate limiting enzyme for lipolysis and one of the two on-off switches for ketosis.