What is the diagnosis for a 60-year-old male with hypertriglyceridemia (Triglycerides, TG, of 323), borderline low Low-Density Lipoprotein (LDL) cholesterol of 83, and low High-Density Lipoprotein (HDL) cholesterol of 32?

From the Guidelines

I strongly recommend starting the patient on a fibrate medication, such as fenofibrate 145mg daily, to address the significantly elevated triglycerides (TG) of 323 mg/dL and low HDL of 32 mg/dL, as suggested by the American Heart Association and the American Diabetes Association 1. The LDL of 83 mg/dL is within target range, but the combination of high triglycerides and low HDL increases cardiovascular risk.

Key Considerations

• The patient's triglyceride level is significantly elevated, which increases the risk of cardiovascular disease, and according to the guidelines, a non-HDL-C goal of 130 mg/dL is a secondary target for patients with triglyceride levels of 200 to 499 mg/dL 1.
• The patient's HDL level is low, which also increases cardiovascular risk, and lifestyle modifications such as weight loss, physical activity, and dietary changes can help improve HDL levels 1.
• The American Heart Association suggests that in patients with triglyceride levels of 200 to 499 mg/dL, a non–HDL-C (total cholesterol minus HDL-C) goal of 130 mg/dL is a secondary target, and fibrate or niacin can be considered as therapeutic options 1.

Lifestyle Modifications

• In addition to medication, the patient should implement lifestyle modifications including:
  • Reducing refined carbohydrates and sugars
  • Limiting alcohol consumption
  • Increasing physical activity to 150 minutes per week
  • Consuming more omega-3 fatty acids through fish or supplements (1-2g daily of EPA/DHA)
  • Weight loss of 5-10% if overweight, as suggested by the American Heart Association 1

Monitoring and Follow-up

• Treatment should be monitored with lipid panels every 3 months initially, along with liver function tests to ensure medication tolerance, as recommended by the guidelines 1.
• If triglycerides remain above 200 mg/dL after 3 months of treatment, adding prescription omega-3 fatty acids could be considered, as suggested by the American Heart Association 1.

From the FDA Drug Label

LOVAZA is a prescription medicine used along with a low-fat and low-cholesterol diet to lower very high triglyceride (fat) levels in adults. The effect of LOVAZA on the risk of pancreatitis has not been determined. The effect of LOVAZA on cardiovascular mortality and morbidity has not been determined. LOVAZA 4 grams per day reduced median TG, VLDL-C, and non-HDL-C levels and increased median HDL-C from baseline relative to placebo. Treatment with LOVAZA to reduce very high TG levels may result in elevations in LDL-C and non-HDL-C in some individuals.

For a 60-year-old male with TG 323, LDL 83, and HDL 32, the use of LOVAZA may help lower triglyceride levels. However, it is essential to monitor LDL-C levels to ensure they do not increase excessively.

• The patient should be advised to follow a low-fat and low-cholesterol diet.
• LDL-C levels should be monitored periodically.
• The patient should be informed that the effect of LOVAZA on cardiovascular mortality and morbidity has not been determined 2.
• The use of LOVAZA may increase LDL-C and non-HDL-C in some individuals, so careful monitoring is necessary.

From the Research

Patient Profile

• Age: 60 years
• Triglycerides (TG): 323
• Low-Density Lipoprotein (LDL): 83
• High-Density Lipoprotein (HDL): 32

Treatment Options

• Fenofibrate:
  • Decreases triglycerides by 29% 3
  • Improves flow-mediated dilation 3
  • Decreases non-HDL cholesterol and triglycerides/HDL cholesterol while increasing HDL cholesterol and apolipoprotein AI 3
  • Decreases fasting insulin and increases plasma adiponectin and insulin sensitivity 3
• Atorvastatin:
  • Decreases all LDL subfractions, including small, dense LDL 4
  • Increases HDL cholesterol by 10% 4
  • More efficient in reducing total cholesterol and LDL cholesterol 5
• Omega-3 fatty acids:
  • Decrease triglycerides by 21% and triglycerides/HDL cholesterol 3
  • Improve flow-mediated dilation 3

Comparison of Treatments

• Fenofibrate vs. Atorvastatin: Fenofibrate is more efficient in reducing triglycerides, while atorvastatin is more efficient in reducing total cholesterol and LDL cholesterol 4, 5
• Fenofibrate vs. Omega-3 fatty acids: Fenofibrate has substantially better effects on lipoprotein and metabolic profiles in patients with hypertriglyceridemia 3

Cardiovascular Risk Reduction

• Statins: Lower the rate of cardiovascular events by lowering LDL cholesterol 6
• Fibrates: Provide additional cardiovascular risk reduction when given in addition to statin treatment 6, 7
• Fenofibrate add-on to statin treatment: Associated with low all-cause death and cardiovascular disease in the general population with high triglyceride levels 7