From the Guidelines
Extremely high triglyceride levels over 1800 mg/dL require immediate and aggressive treatment to prevent acute pancreatitis, and the first step is implementing a very low-fat diet (less than 15% of calories from fat) and completely avoiding alcohol, as recommended by the 2021 ACC expert consensus decision pathway on the management of ASCVD risk reduction in patients with persistent hypertriglyceridemia 1. The management of such high triglyceride levels should prioritize reducing the risk of acute pancreatitis, which can be achieved through lifestyle modifications and pharmacotherapy.
- Key lifestyle modifications include:
- Implementing a very low-fat diet (less than 15% of calories from fat)
- Completely avoiding alcohol
- Restricting carbohydrate intake, particularly simple sugars and refined carbohydrates
- Medication therapy should begin with a high-dose prescription omega-3 fatty acid, such as Vascepa (icosapent ethyl) 2 grams twice daily or Lovaza (omega-3-acid ethyl esters) 4 grams daily, as recommended by the 2021 ACC expert consensus decision pathway on the management of ASCVD risk reduction in patients with persistent hypertriglyceridemia 1.
- A fibrate medication, like fenofibrate 145 mg daily or gemfibrozil 600 mg twice daily, should be added to further reduce triglyceride levels, as suggested by the 2021 ACC expert consensus decision pathway on the management of ASCVD risk reduction in patients with persistent hypertriglyceridemia 1.
- For severe cases, insulin therapy may be necessary even in non-diabetic patients to rapidly lower triglycerides, as mentioned in the 2021 ACC expert consensus decision pathway on the management of ASCVD risk reduction in patients with persistent hypertriglyceridemia 1.
- Once levels decrease below 500 mg/dL, a high-potency statin, like rosuvastatin 20-40 mg or atorvastatin 40-80 mg daily, can be added to reduce the risk of cardiovascular events, as recommended by the 2025 cardiovascular disease and risk management standards of care in diabetes 1. Regular monitoring every 4-6 weeks is essential until levels stabilize below 500 mg/dL, as the aggressive approach is necessary because extremely high triglycerides can cause pancreatic inflammation when chylomicrons physically obstruct pancreatic capillaries, leading to potentially life-threatening pancreatitis.
From the FDA Drug Label
Fenofibrate tablets are also indicated as adjunctive therapy to diet for treatment of adult patients with severe hypertriglyceridemia. Improving glycemic control in diabetic patients showing fasting chylomicronemia will usually obviate the need for pharmacologic intervention. Markedly elevated levels of serum triglycerides (e.g., > 2,000 mg/dL) may increase the risk of developing pancreatitis.
For patients with triglycerides over 1800, the management and treatment should include:
- Dietary therapy: as the initial treatment for dyslipidemia
- Fenofibrate tablets: as adjunctive therapy to diet for the treatment of adult patients with severe hypertriglyceridemia
- Improving glycemic control: in diabetic patients showing fasting chylomicronemia to obviate the need for pharmacologic intervention
- Monitoring: for the risk of developing pancreatitis, although the effect of fenofibrate therapy on reducing this risk has not been adequately studied 2 2 2
From the Research
Management of Triglycerides over 1800
Triglyceride levels over 1800 mg/dL are considered severely elevated and increase the risk of pancreatitis 3, 4, 5, 6.
Treatment Options
- Dietary changes and lifestyle modifications are recommended as the first line of treatment for hypertriglyceridemia, including lowering carbohydrate intake and increasing fat and protein intake 5, 6.
- Statins can be considered for patients with high triglyceride levels who have borderline or intermediate risk of atherosclerotic cardiovascular disease 5.
- For patients with severely elevated triglyceride levels, fibrates, omega-3 fatty acids, or niacin can be considered to reduce the risk of pancreatitis 4, 5, 6.
- High-dose icosapent (purified eicosapentaenoic acid) can reduce cardiovascular mortality in patients with high triglyceride levels despite statin use 5.
- Prescription omega-3 fatty acids (P-OM3) and fenofibrate (FENO) are effective lipid-altering agents that reduce triglyceride levels, and concomitant use of P-OM3 and FENO can result in a greater reduction in triglyceride levels than FENO alone 7.
Additional Considerations
- Insulin infusion and plasmapheresis should be considered for patients with acute pancreatitis associated with hypertriglyceridemia if triglyceride levels remain high despite conservative management 5.
- Correcting secondary causes of hypertriglyceridemia, such as obesity, uncontrolled diabetes, and alcohol misuse, is important before starting drug treatment 6.