What is the treatment for hypertriglyceridemia?

From the Guidelines

Hypertriglyceridemia treatment should prioritize lifestyle modifications, including dietary changes and increased physical activity, as the foundation of management, as emphasized by the 2021 ACC expert consensus decision pathway 1.

Key Components of Treatment

• Lifestyle intervention remains the critical component of ASCVD risk reduction, both before and in concert with the use of lipid-lowering medications 1.
• Referral to a registered dietitian nutritionist is strongly recommended to improve understanding of heart-healthy dietary principles and individualize nutrition recommendations for patients with hypertriglyceridemia 1.
• Adherence to lifestyle modification should be regularly assessed at the time of initiation or modification of statin therapy and at each patient visit during monitoring of ongoing therapy 1.

Medication Therapy

• For patients with triglyceride levels above 500 mg/dL, medication therapy is typically recommended to reduce the risk of pancreatitis, with first-line pharmacological options including fibrates, omega-3 fatty acids, and statins 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 1.

Treatment Goals

• The goal of treatment is to reduce triglycerides below 500 mg/dL to minimize pancreatitis risk and below 150 mg/dL for optimal cardiovascular health 1.
• Regular monitoring of lipid levels is important to assess treatment efficacy 1.

Recent Guidelines

• The 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol recommends reducing both atherogenic VLDL and associated risk factors by nonpharmacological means where possible 1.
• The guideline also suggests that initiation of statin therapy is reasonable in patients with severe hypertriglyceridemia, but stresses that statins alone cannot prevent increasing levels of triglycerides in the face of secondary causes from triggering acute hypertriglyceridemic pancreatitis 1.

From the FDA Drug Label

1. 2 Severe Hypertriglyceridemia Fenofibrate tablets are also indicated as adjunctive therapy to diet for treatment of adult patients with severe hypertriglyceridemia. The initial dose is 54 mg per day to 160 mg per day. Dosage should be individualized according to patient response and should be adjusted if necessary following repeat lipid determinations at 4 to 8 week intervals. The maximum dose is 160 mg once daily.

Treatment of Hypertriglyceridemia: Fenofibrate is indicated as adjunctive therapy to diet for the treatment of adult patients with severe hypertriglyceridemia.

• The initial dose of fenofibrate for severe hypertriglyceridemia is 54 mg per day to 160 mg per day.
• The dosage should be individualized according to patient response.
• The maximum dose is 160 mg once daily 2, 2.
• It is essential to monitor lipid levels periodically and adjust the dosage as needed 2.

From the Research

Treatment Options for Hypertriglyceridemia

• Lifestyle changes, such as improved diet and increased physical activity, are effective in lowering triglyceride levels 3, 4, 5
• Pharmacological treatment usually starts with statins, although associated triglyceride reductions are typically modest 3, 6
• Fibrates are currently the drugs of choice for hypertriglyceridemia, frequently in combination with statins 3, 4, 6
• Niacin and omega-3 fatty acids can improve control of triglyceride levels when other measures are inadequately effective 3, 7, 6
• Novel therapies, including anti-sense oligonucleotides and inhibitors of microsomal triglyceride transfer protein, have shown significant triglyceride lowering efficacy 3

Management of Hypertriglyceridemia

• The individual risk of cardiovascular disease and of pancreatitis must be estimated in order to decide whether, and how, hypertriglyceridemia should be treated 4
• 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 4, 5
• Calculating a patient's 10-year risk of atherosclerotic cardiovascular disease is pertinent to determine the role of medications 5
• Statins can be considered for patients with high triglyceride levels who have borderline or intermediate risk 5
• High-dose icosapent (purified eicosapentaenoic acid) can reduce cardiovascular mortality in patients at high risk who continue to have high triglyceride levels despite statin use 5

Triglyceride-Lowering Agents

• Long-chain omega-3 fatty acids, fibrates, and niacin are therapeutic options in the treatment of hypertriglyceridemia 7, 6
• Omega-3 fatty acids can lower triglyceride levels by 45% and very low-density lipoprotein cholesterol levels by more than 50% in patients with triglyceride levels above 500 mg/dl 7
• Fibrates can lower triglyceride concentrations, but their efficacy in combination with statins has not been clearly shown in endpoint studies 4
• Niacin can improve control of triglyceride levels, but its use is limited due to adverse effects 6