From the Guidelines
The workup for significantly elevated triglycerides should begin with a comprehensive lipid panel to confirm the elevation and assess other lipid parameters, followed by immediate dietary intervention and consideration of pharmacologic therapy to reduce the risk of pancreatitis and cardiovascular disease. Initial evaluation should include a detailed medical history focusing on risk factors such as diabetes, obesity, alcohol use, and medication review, as some drugs like estrogens, corticosteroids, and certain antipsychotics can raise triglycerides 1. Physical examination should assess for signs of metabolic syndrome, pancreatitis, and xanthomas. Laboratory testing should include fasting glucose, HbA1c, liver function tests, thyroid function tests, and renal function to identify secondary causes.
Key Considerations
- For severe hypertriglyceridemia (>500 mg/dL), immediate dietary intervention is crucial, including restricting fat intake to <15% of calories, eliminating alcohol, and controlling carbohydrate intake 1.
- Pharmacologic therapy typically starts with fibrates like fenofibrate or gemfibrozil, often combined with high-dose omega-3 fatty acids (2-4 g daily) 1.
- For extremely high levels (>1000 mg/dL) with risk of pancreatitis, hospitalization may be necessary for more aggressive management.
- Statins may be added if LDL cholesterol is also elevated.
- Lifestyle modifications including weight loss, regular exercise, and dietary changes are fundamental to long-term management.
Management Strategies
- Evaluate for secondary causes of hypertriglyceridemia and consider medical therapy to reduce the risk of pancreatitis for patients with fasting triglyceride levels ≥500 mg/dL 1.
- Address and treat lifestyle factors, secondary factors, and medications that raise triglycerides in adults with moderate hypertriglyceridemia (fasting or non–fasting triglycerides 175–499 mg/dL) 1.
- Consider the addition of icosapent ethyl to reduce cardiovascular risk in patients with atherosclerotic cardiovascular disease or other cardiovascular risk factors on a statin with controlled LDL cholesterol but elevated triglycerides (135–499 mg/dL) 1.
From the FDA Drug Label
The initial treatment for dyslipidemia is dietary therapy specific for the type of lipoprotein abnormality. Excess body weight and excess alcoholic intake may be important factors in hypertriglyceridemia and should be addressed prior to any drug therapy. Physical exercise can be an important ancillary measure Diseases contributory to hyperlipidemia, such as hypothyroidism or diabetes mellitus should be looked for and adequately treated. Estrogen therapy, thiazide diuretics and beta-blockers, are sometimes associated with massive rises in plasma triglycerides, especially in subjects with familial hypertriglyceridemia In such cases, discontinuation of the specific etiologic agent may obviate the need for specific drug therapy of hypertriglyceridemia.
The workup for significant elevated triglycerides includes:
- Dietary therapy: specific for the type of lipoprotein abnormality
- Addressing excess body weight and alcoholic intake
- Physical exercise as an ancillary measure
- Treating contributory diseases such as hypothyroidism or diabetes mellitus
- Discontinuing etiologic agents such as estrogen therapy, thiazide diuretics, and beta-blockers if associated with massive rises in plasma triglycerides 2
From the Research
Workup for Significant Elevated Triglycerides
The workup for significant elevated triglycerides involves a combination of lifestyle modifications, dietary changes, and medication.
- The initial step is to assess the patient's risk factors for hypertriglyceridemia, including obesity, metabolic syndrome, and type 2 diabetes mellitus 3.
- 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.
- Dietary changes, including lowering carbohydrate intake and increasing fat and protein intake, can also help lower triglyceride levels 3.
- For patients with severely elevated triglyceride levels (≥500 mg/dL), medication such as fibrates, omega-3 fatty acids, or niacin may be considered to reduce the risk of pancreatitis 3, 4.
- Statins can be considered for patients with high triglyceride levels who have borderline or intermediate risk of atherosclerotic cardiovascular disease 3.
- 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 3.
Laboratory Tests
Laboratory tests, such as fasting serum triglyceride levels, low-density lipoprotein (LDL) cholesterol, and high-density lipoprotein (HDL) cholesterol, can help assess the patient's lipid profile and guide treatment decisions 5, 6.
- Calculating a patient's 10-year risk of atherosclerotic cardiovascular disease is also important to determine the role of medications 3.
Treatment Options
Treatment options for hypertriglyceridemia include: