What is the preferred treatment for hypertriglyceridemia?

From the Guidelines

Treatment for hypertriglyceridemia should begin with lifestyle modifications, including a low-fat diet, regular exercise, weight loss if overweight, and avoiding alcohol, with medication considered for higher levels (≥500 mg/dL) to reduce the risk of pancreatitis, as recommended by the most recent guidelines 1. The goal of treatment is to reduce triglyceride levels and decrease the risk of cardiovascular disease and pancreatitis.

• Lifestyle modifications are the first line of therapy, with a focus on weight loss, dietary changes, and increased physical activity.
• For moderate elevations (150-499 mg/dL), lifestyle modifications are often sufficient, but for higher levels (≥500 mg/dL), medication may be necessary.
• First-line pharmacological treatment includes statins, fibrates, and omega-3 fatty acids, which can lower triglycerides by 20-50% 1.
• In very severe cases (>1000 mg/dL), combination therapy may be necessary, and medications such as niacin may be considered, although they can have more side effects 1. The most recent guidelines recommend that for individuals with fasting triglyceride levels ≥500 mg/dL, medical therapy should be considered to reduce the risk of pancreatitis, and lifestyle interventions, including medical nutrition therapy, should be implemented to reduce excesses in both chylomicrons and VLDL 1.
• Regular monitoring of lipid levels is essential to assess treatment effectiveness, typically every 4-12 weeks initially, then every 3-12 months once stable.
• The treatment goal for patients with moderate hypertriglyceridemia is 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.

From the FDA Drug Label

The initial treatment for dyslipidemia is dietary therapy specific for the type of lipoprotein abnormality. Fenofibrate tablets are indicated as adjunctive therapy to diet to reduce elevated low-density lipoprotein cholesterol (LDL-C), total cholesterol (Total-C), Triglycerides and apolipoprotein B (Apo B), and to increase high-density lipoprotein cholesterol (HDL-C) in adult patients with primary hypercholesterolemia or mixed dyslipidemia. Fenofibrate tablets are also indicated as adjunctive therapy to diet for treatment of adult patients with severe hypertriglyceridemia.

The preferred treatment for hypertriglyceridemia is:

• Dietary therapy as the initial treatment
• Fenofibrate as adjunctive therapy to diet for reducing elevated triglycerides and other lipids in adult patients with primary hypercholesterolemia or mixed dyslipidemia, and for treating adult patients with severe hypertriglyceridemia. Key considerations:
• Dose individualization according to patient response
• Monitoring of lipid levels and adjustment of dosage as necessary
• Maximum dose of 160 mg once daily 2 2 2

From the Research

Hypertriglyceridemia Treatment Options

The treatment of hypertriglyceridemia involves a combination of lifestyle changes and pharmacological interventions.

• Lifestyle changes, such as improved diet and increased physical activity, are effective in lowering triglyceride levels 3.
• Dietary changes, including reduced intake of rapidly metabolized carbohydrates and increased intake of omega-3 fatty acids, can help lower triglyceride levels 4, 5.
• Weight loss and blood sugar control are also important in managing hypertriglyceridemia 4, 6.

Pharmacological Treatment

Pharmacological treatment usually starts with statins, although the associated triglyceride reductions are typically modest 3.

• Fibrates are currently the drugs of choice for hypertriglyceridemia, frequently in combination with statins 3, 6.
• Omega-3 fatty acids and niacin can also be used to improve control of triglyceride levels when other measures are inadequately effective 3, 5.
• High-dose icosapent (purified eicosapentaenoic acid) can reduce cardiovascular mortality in patients with high triglyceride levels despite statin use 5.

Special Considerations

Patients with severely elevated triglyceride levels (500 mg/dL or higher) are at increased risk of pancreatitis and may require specific drug treatment to lower triglyceride levels 4, 5.

• Patients with acute pancreatitis associated with hypertriglyceridemia may require insulin infusion and plasmapheresis if triglyceride levels remain high despite conservative management 5.
• Family screening is mandatory to detect familial lipid disorders and allow for early intervention in other family members 6.