What is the management for a 34-year-old female on olanzapine (olanzapine) with severe hypertriglyceridemia?

From the Guidelines

The management for a 34-year-old female on olanzapine with a severely elevated triglyceride level of 760 mg/dL should focus on both medication and lifestyle interventions, prioritizing the initiation of a fibrate medication such as fenofibrate 145 mg daily or gemfibrozil 600 mg twice daily to rapidly lower triglyceride levels and reduce the risk of pancreatitis, as recommended by the most recent guidelines 1.

Medication Interventions

• Consider starting the patient on a fibrate medication such as fenofibrate 145 mg daily or gemfibrozil 600 mg twice daily to rapidly lower triglyceride levels and reduce the risk of pancreatitis, as supported by studies 1.
• Additionally, prescribe a high-intensity statin like atorvastatin 40-80 mg daily or rosuvastatin 20-40 mg daily to address overall lipid management, as recommended by guidelines 1.

Lifestyle Modifications

• Lifestyle modifications are crucial and should include a low-fat diet (less than 15% of calories from fat), avoidance of alcohol and simple sugars, regular aerobic exercise for 150 minutes weekly, and weight loss if the patient is overweight, as advised by recent consensus 1.
• Limit intake of added sugars, sugar sweetened beverages, and desserts, and advise patients to consume whole fruit and avoid fruit juices when possible, as recommended by the American College of Cardiology 1.

Monitoring and Adjustment

• Monitor triglyceride levels every 4-6 weeks initially until stabilized, then every 3-6 months, and adjust medication and lifestyle interventions as needed to achieve and maintain triglyceride levels below 500 mg/dL.
• If triglycerides remain above 500 mg/dL despite these interventions, consider adding omega-3 fatty acids (2-4 g daily) or referring to a lipid specialist, as suggested by guidelines 1.

Consideration of Medication-Induced Cause

• Since olanzapine is likely contributing to the hypertriglyceridemia, consult with the patient's psychiatrist about possibly switching to an antipsychotic with less metabolic impact, such as aripiprazole or ziprasidone, if clinically appropriate, as recommended by studies 1.

From the FDA Drug Label

Olanzapine Monotherapy in Adults — In an analysis of 5 placebo-controlled olanzapine monotherapy studies with treatment duration up to 12 weeks, olanzapine-treated patients had increases from baseline in mean fasting total cholesterol, LDL cholesterol, and triglycerides of 5.3 mg/dL, 3.0 mg/dL, and 20. 8 mg/dL respectively Table 4 shows categorical changes in fasting lipids values FastingTriglycerides Increase by ≥50 mg/dL Olanzapine 745 39.6% Placebo 402 26.1% Normal to High (<150 mg/dL to ≥200 mg/dL) Olanzapine 457 9.2% Placebo 251 4.4%

The management of a 34-year-old female patient on olanzapine with a triglyceride level of 760 going forward should include:

• Monitoring and evaluation of the patient's lipid profile and cardiovascular risk factors
• Consideration of alternative treatments that may have a more favorable metabolic profile
• Lifestyle modifications such as diet and exercise to help manage triglyceride levels
• Pharmacological interventions such as lipid-lowering agents may be necessary to manage the patient's triglyceride levels 2
• Regular monitoring of the patient's weight, glucose, and lipid profiles is recommended 2

From the Research

Management of Hypertriglyceridemia

The patient's triglyceride level of 760 mg/dL is considered severe hypertriglyceridemia, which is a risk factor for acute pancreatitis and cardiovascular disease 3.

Treatment Options

• Fenofibrate therapy has been shown to be effective in reducing triglyceride levels in patients with hypertriglyceridemia 4, 5, 6.
• Long-chain omega-3 fatty acids may be a well-tolerated and effective alternative to fibrates and niacin in reducing triglyceride levels 3, 7.
• Statins are the first line of therapy for the management of mild to moderate hypertriglyceridemia, but may not be sufficient for severe hypertriglyceridemia 3.

Combination Therapy

• The concomitant use of prescription omega-3 fatty acids and fenofibrate has been shown to result in a greater reduction in triglyceride levels compared to fenofibrate monotherapy 7.
• The addition of prescription omega-3 fatty acids to stable fenofibrate therapy has been shown to result in a statistically significant reduction in triglyceride levels 7.

Safety and Efficacy

• Fenofibrate has been shown to be well-tolerated in patients with hypertriglyceridemia, with common adverse events including gastrointestinal disturbances, headache, and muscle cramps 4, 5, 6.
• The safety and efficacy of fenofibrate in routine treatment of patients with hypertriglyceridemia and metabolic syndrome has been demonstrated in a real-world setting 6.