Atypical antipsychotic agents including clozapine and olanzapine, cause less extrapyramidal side effects than conventional agents however they are associated with adverse metabolic side effects [1-2]. We report a case of diabetic ketoacidosis and a very severe hypertriglyceridaemia with triglycerides of 56.4mmol/L associated with clozapine use in a patient with schizoaffective disorder, poorly controlled type 2 diabetes and a normal BMI. The patient was successfully treated with continuous insulin infusion, electrolyte replacement and intravenous fluids in the high dependency unit. The insulin infusion was continued for 92 hours (329 units of insulin in total) and it was discontinued when the triglycerides reached 10mmol/L, with normalisation of his lipid profile and diabetes control while on basal bolus insulin regime, fenofibrate and rosuvastatin. Importantly the patient has achieved satisfactory long term lipid and glycaemic control in spite of continuation of clozapine for his schizoaffective disorder. The current recommendations related to the metabolic care for patients treated with atypical antipsychotic agents as well as the mechanisms behind abnormal glucose and lipid regulation with clozapine therapy are discussed.