From the Guidelines
Hypertriglyceridemia should be addressed with dietary and lifestyle changes, including weight loss and abstinence from alcohol, and for severe cases, pharmacologic therapy with fibrates, omega-3 fatty acids, or statins may be necessary to reduce the risk of acute pancreatitis and cardiovascular events. The management of hypertriglyceridemia depends on the severity of the condition, with lifestyle modifications being the first-line approach for most patients 1. These modifications include adopting a low-fat diet, reducing simple carbohydrate intake, eliminating alcohol consumption, and engaging in regular physical activity.
For patients with moderate hypertriglyceridemia, the treatment goal is to achieve a non–high-density lipoprotein cholesterol level of 30 mg per dL higher than the low-density lipoprotein goal, as recommended by the NCEP ATP III 1. Fibrates are the first-line treatment in patients with hypertriglyceridemia who are at risk of pancreatitis, while statins have a modest triglyceride-lowering effect and may be useful to modify cardiovascular risk in patients with moderately elevated triglyceride levels.
The Reduction of Cardiovascular Events with Icosapent Ethyl–Intervention Trial (REDUCE-IT) demonstrated a 25% relative risk reduction for the primary end point composite of cardiovascular death, nonfatal myocardial infarction, nonfatal stroke, coronary revascularization, or unstable angina with the use of icosapent ethyl 4 g/day in patients with moderately elevated triglycerides 1. This study highlights the importance of considering omega-3 fatty acid therapy in the management of hypertriglyceridemia, particularly in patients with established cardiovascular disease or at high risk of cardiovascular events.
Key considerations in the management of hypertriglyceridemia include:
- Lifestyle modifications, including dietary changes and increased physical activity
- Pharmacologic therapy with fibrates, omega-3 fatty acids, or statins for severe cases
- Monitoring of lipid panels to assess response to treatment and adjust therapy as needed
- Consideration of omega-3 fatty acid therapy in patients with established cardiovascular disease or at high risk of cardiovascular events, as supported by the REDUCE-IT trial 1.
From the FDA Drug Label
Fenofibrate tablets are also indicated as adjunctive therapy to diet for treatment of adult patients with severe hypertriglyceridemia. Improving glycemic control in diabetic patients showing fasting chylomicronemia will usually obviate the need for pharmacologic intervention. Markedly elevated levels of serum triglycerides (e.g., > 2,000 mg/dL) may increase the risk of developing pancreatitis.
Treatment of Hypertriglyceridemia: Fenofibrate is indicated as adjunctive therapy to diet for the treatment of adult patients with severe hypertriglyceridemia.
- The initial dose for severe hypertriglyceridemia is 54 mg per day to 160 mg per day.
- Dosage should be individualized according to patient response and adjusted if necessary following repeat lipid determinations at 4 to 8 week intervals.
- The maximum dose is 160 mg once daily 2.
From the Research
Definition and Prevalence of Hypertriglyceridemia
- Hypertriglyceridemia is a condition characterized by elevated levels of triglycerides in the blood, affecting 15-20% of the adult population 3 and approximately 33% of the US population 4.
- It is often associated with overweight, metabolic syndrome, and diabetes mellitus, and can be discovered incidentally 3.
Risks and Complications
- Elevated triglyceride levels are causally linked to cardiovascular disease and can induce acute pancreatitis if levels exceed 1000 mg/dL (11.4 mmol/L) 3.
- Severe hypertriglyceridemia is a risk factor for acute pancreatitis, and guidelines recommend immediate use of triglyceride-lowering agents for severe cases 4.
Treatment and Management
- Lifestyle modifications, such as cessation of alcohol consumption, reduced intake of rapidly metabolized carbohydrates, weight loss, and blood sugar control, are the most effective ways to lower triglyceride levels 3.
- Pharmacological treatment may include statins, fibrates, niacin, and omega-3 fatty acids, with the goal of reducing the risk of pancreatitis and cardiovascular disease 4, 5, 6, 7.
- A daily dose of 2-4 g omega-3 fatty acids can lower triglyceride levels, and prescription omega-3 fatty acids have been approved as an adjunct to diet for the treatment of very high triglyceride levels 3, 6.
Specific Treatment Options
- Fibrates can lower triglyceride concentrations, but their efficacy in combination with statins has not been clearly shown in endpoint studies 3.
- Niacin and omega-3 fatty acids can improve control of triglyceride levels when other measures are inadequately effective 5.
- Novel therapies, including anti-sense oligonucleotides and inhibitors of microsomal triglyceride transfer protein, have shown significant triglyceride-lowering efficacy 5.