What medication to start for hypertriglyceridemia?

From the Guidelines

For hypertriglyceridemia, fibrates like fenofibrate (145 mg daily) or gemfibrozil (600 mg twice daily) are typically the first-line medications as they can reduce triglycerides by 30-50%. Lifestyle modifications are the first step, including weight loss, reduced alcohol intake, and limiting simple carbohydrates. If triglycerides remain above 500 mg/dL despite lifestyle changes, medication is indicated to reduce pancreatitis risk 1. Omega-3 fatty acids (2-4 g daily) are another option, either as prescription formulations like Lovaza or Vascepa, or as supplements. For patients with moderately elevated triglycerides (200-499 mg/dL) who also have elevated LDL cholesterol, statins like atorvastatin (10-80 mg daily) or rosuvastatin (5-40 mg daily) may be appropriate. 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 icosapent ethyl 4 g/day (2 g twice daily with food) versus placebo 1. Niacin (1-2 g daily) is less commonly used due to side effects like flushing and potential liver issues. Treatment should be individualized based on triglyceride levels, cardiovascular risk factors, and comorbidities. Regular monitoring of lipid levels and liver function is necessary to assess treatment efficacy and safety.

Some key points to consider when treating hypertriglyceridemia include:

• Assessing for other cardiovascular risk factors, such as central obesity, hypertension, abnormal glucose metabolism, and liver dysfunction 1
• Evaluating for family history of dyslipidemia and cardiovascular disease 1
• Considering the use of fibrates, niacin, and n-3 fatty acids, alone or in combination, for patients with moderate to severe hypertriglyceridemia 1
• Using statins to modify cardiovascular risk in patients with moderately elevated triglyceride levels, but not as the sole treatment for severe or very severe hypertriglyceridemia 1

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Medication Options for Hypertriglyceridemia

The following medications can be considered for the treatment of hypertriglyceridemia:

• Statins: recommended as the first line of therapy for mild to moderate hypertriglyceridemia 2, 3, 4
• Fibrates: can be used as an adjunct to statin therapy or as a first-line option for patients with severely elevated triglyceride levels 2, 3, 4, 5, 6
• Omega-3 fatty acids: can be used as an adjunct to statin or fibrate therapy, or as a first-line option for patients with severely elevated triglyceride levels 2, 3, 4, 5, 6
• Niacin: can be used as an adjunct to statin or fibrate therapy, or as a first-line option for patients with severely elevated triglyceride levels 2, 3, 4, 6

Considerations for Medication Selection

When selecting a medication for hypertriglyceridemia, the following factors should be considered:

• Severity of hypertriglyceridemia: patients with severely elevated triglyceride levels may require more aggressive treatment with fibrates, omega-3 fatty acids, or niacin 2, 3, 4, 5, 6
• Presence of other cardiovascular risk factors: patients with multiple cardiovascular risk factors may require more aggressive treatment with statins or combination therapy 2, 3, 4
• Patient tolerance and adherence: patients who are intolerant of statins or fibrates may require alternative treatments with omega-3 fatty acids or niacin 2, 3, 4, 5, 6

Combination Therapy

Combination therapy with multiple medications may be necessary to achieve optimal triglyceride lowering and reduce cardiovascular risk:

• Statin + fibrate: can be used for patients with mild to moderate hypertriglyceridemia and elevated low-density lipoprotein cholesterol levels 2, 3, 4, 6
• Statin + omega-3 fatty acids: can be used for patients with mild to moderate hypertriglyceridemia and elevated triglyceride levels 2, 3, 4, 5, 6
• Fibrate + omega-3 fatty acids: can be used for patients with severely elevated triglyceride levels and elevated low-density lipoprotein cholesterol levels 5