From the Guidelines
For hypertriglyceridemia with a serum triglyceride level of 350 mg/dL, the first-line treatment is a combination of lifestyle modifications and fibrates, as fibrates are the first-line treatment in patients with hypertriglyceridemia who are at risk of pancreatitis, as stated in the guidelines 1.
Lifestyle Modifications
Lifestyle changes should include:
- A low-fat diet (less than 30% of calories from fat)
- Weight loss if overweight
- Regular aerobic exercise (at least 150 minutes per week)
- Alcohol restriction
- Smoking cessation These interventions work by reducing hepatic triglyceride production and increasing triglyceride clearance from the bloodstream.
Pharmacotherapy
For medication, fibrates such as fenofibrate 48-145 mg daily are the first-line pharmacologic treatment for patients with hypertriglyceridemia who are at risk of pancreatitis 1. Omega-3 fatty acids (2-4 grams daily) may also be beneficial as an adjunct therapy. Statins have a modest triglyceride-lowering effect (typically 10% to 15%) and may be useful to modify cardiovascular risk in patients with moderately elevated triglyceride levels, but they should not be used alone in patients with severe or very severe hypertriglyceridemia 1.
Monitoring and Goals
Regular monitoring of lipid levels is necessary to assess treatment efficacy, with a goal of reducing triglycerides to below 150 mg/dL to minimize the risk of pancreatitis and cardiovascular disease. The treatment goal for patients with moderate hypertriglyceridemia is a non–high-density lipoprotein cholesterol level of 30 mg per dL (0.78 mmol per L) higher than the low-density lipoprotein goal, as recommended by the NCEP ATP III 1.
From the FDA Drug Label
The initial treatment for dyslipidemia is dietary therapy specific for the type of lipoprotein abnormality.
2.2 Primary Hypercholesterolemia or Mixed Dyslipidemia The initial dose of fenofibrate tablet is 160 mg once daily.
2.3 Severe Hypertriglyceridemia The initial dose is 54 mg per day to 160 mg per day.
The first line treatment for hypertriglyceridemia with a serum triglyceride of 350 is dietary therapy. If drug therapy is needed, the initial dose of fenofibrate can be 54 mg per day to 160 mg per day for severe hypertriglyceridemia 2.
From the Research
First Line Treatment for Hypertriglyceridemia
The first line treatment for hypertriglyceridemia with a serum triglyceride of 350 mg/dL involves lifestyle modifications and potentially medication.
- Dietary changes, such as lowering carbohydrate intake and increasing fat and protein intake, can help lower triglyceride levels 3.
- Moderate- to high-intensity physical activity can also lower triglyceride levels and improve overall cardiovascular health 3.
- For patients with high triglyceride levels, statins can be considered, especially if they have a borderline or intermediate risk of atherosclerotic cardiovascular disease 3, 4.
- According to guidelines, statins remain the first line of therapy for the management of mild to moderate hypertriglyceridemia (150-499 mg/dL) 4.
Medication Options
In addition to lifestyle modifications and statins, other medication options may be considered for patients with hypertriglyceridemia.
- Fibrates, omega-3 fatty acids, or niacin may be considered for patients with severely elevated triglyceride levels to reduce the risk of pancreatitis 3, 4.
- 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.
- Prescription omega-3 fatty acids can be used as an adjunct to fenofibrate therapy in hypertriglyceridemic subjects, resulting in a significant reduction in triglyceride levels 5.
Patient-Specific Considerations
When determining the first line treatment for hypertriglyceridemia, patient-specific considerations should be taken into account.
- Evaluating for secondary contributors, such as diabetes mellitus, is an important step in managing moderate hypertriglyceridemia 6.
- Lifestyle adjustments, such as weight loss and decreasing alcohol consumption, should be aimed at reducing triglyceride levels and improving overall cardiovascular health 6.