What is the management of hypertriglyceridemia?

From the Guidelines

Lifestyle interventions, including dietary changes and weight loss, should be the first line of therapy for managing hypertriglyceridemia, as they have been shown to effectively lower triglyceride levels and improve overall health outcomes. According to the 2021 ACC expert consensus decision pathway on the management of ASCVD risk reduction in patients with persistent hypertriglyceridemia 1, lifestyle interventions are recommended as the initial approach for managing hypertriglyceridemia. This includes dietary changes such as reducing intake of simple carbohydrates, alcohol, and saturated fats, as well as increasing consumption of omega-3 fatty acids and fiber. Weight loss for overweight individuals, regular exercise (at least 150 minutes weekly of moderate-intensity activity), and strict glycemic control for diabetic patients are also essential components of lifestyle interventions.

Some key points to consider in the management of hypertriglyceridemia include:

• Dietary changes: reducing intake of simple carbohydrates, alcohol, and saturated fats, and increasing consumption of omega-3 fatty acids and fiber
• Weight loss: aiming for a 5-10% reduction in body weight to achieve a 20% decrease in triglycerides
• Exercise: regular physical activity, such as at least 150 minutes weekly of moderate-intensity activity
• Glycemic control: strict control of blood sugar levels for diabetic patients

For pharmacotherapy, the choice of medication depends on the severity of hypertriglyceridemia and the presence of other cardiovascular risk factors. According to the 2022 standards of medical care in diabetes 1, icosapent ethyl can be considered 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). Fibrates, such as fenofibrate, may be preferred for severe hypertriglyceridemia (≥500 mg/dL) to reduce the risk of pancreatitis.

Key pharmacotherapy options include:

• Statins: for moderate elevations (150-499 mg/dL)
• Fibrates: for severe hypertriglyceridemia (≥500 mg/dL)
• Icosapent ethyl: for patients with atherosclerotic cardiovascular disease or other cardiovascular risk factors on a statin with controlled LDL cholesterol but elevated triglycerides (135-499 mg/dL)

Regular monitoring of triglyceride levels and adjustment of therapy as needed is crucial to achieve optimal outcomes. The treatment targets vary by risk category, but generally aim for triglycerides below 150 mg/dL. As recommended by the Endocrine Society guidelines on the diagnosis and management of hypertriglyceridemia 1, initial treatment of patients with mild to moderate hypertriglyceridemia should include dietary counseling and weight loss in patients who are overweight or obese.

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. Fenofibrate tablets are indicated as adjunctive therapy to diet for treatment of adult patients with severe hypertriglyceridemia. The initial dose is 54 mg per day to 160 mg per day. Dosage should be individualized according to patient response and should be adjusted if necessary following repeat lipid determinations at 4 to 8 week intervals.

Management of Hypertriglyceridemia:

• The initial approach is dietary therapy specific for the type of lipoprotein abnormality.
• Fenofibrate can be used as adjunctive therapy to diet for the treatment of adult patients with severe hypertriglyceridemia.
• The recommended initial dose of fenofibrate is 54 mg per day to 160 mg per day, with individualized dosage adjustments based on patient response and lipid level monitoring 2.
• It is also important to address excess body weight and excess alcoholic intake, as these may be contributing factors to hypertriglyceridemia 2.

From the Research

Management of Hypertriglyceridemia

The management of hypertriglyceridemia involves a combination of lifestyle modifications and pharmacological interventions.

• 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 (TG) levels 3.
• The need to lower low-density lipoprotein (LDL) concentration must be determined on the basis of cardiovascular risk, independently of the success of lifestyle changes 3.
• For patients with high triglyceride levels, calculating the 10-year risk of atherosclerotic cardiovascular disease is pertinent to determine the role of medications 4.

Pharmacological Interventions

• Few patients need specific drug treatment to lower TG levels, and fibrates can lower TG concentrations, but their efficacy in combination with statins has not been clearly shown in endpoint studies 3.
• A daily dose of 2-4 g omega-3 fatty acids can also lower TG levels 3.
• Statins can be considered for patients with high triglyceride levels who have borderline or intermediate risk 4.
• For patients at high risk who continue to have high triglyceride levels despite statin use, high-dose icosapent (purified eicosapentaenoic acid) can reduce cardiovascular mortality 4.
• Fibrates, omega-3 fatty acids, or niacin should be considered for patients with severely elevated triglyceride levels to reduce the risk of pancreatitis 4.
• Long-chain omega-3 fatty acids may be a well-tolerated and effective alternative to fibrates and niacin, yet further large-scale clinical studies are required to evaluate their effects on cardiovascular outcomes and CVD risk reduction in patients with hypertriglyceridemia 5.

Combination Therapy

• Concomitant use of prescription omega-3 fatty acids (P-OM3) and fenofibrate (FENO) can result in a greater reduction in TG levels compared to FENO monotherapy 6.
• The addition of P-OM3 to stable FENO therapy can result in a statistically significant reduction in TG levels 6.
• A head-to-head comparison of omega-3 fatty acids and fenofibrate showed that fenofibrate therapy had substantially better effects on lipoprotein and metabolic profiles in patients with hypertriglyceridemia 7.