From the Guidelines
Severe hypertriglyceridemia (triglyceride levels >1000 mg/dL) requires immediate treatment with lifestyle modifications and medication therapy to prevent acute pancreatitis, with the primary approach involving dietary modifications, such as restricting fat intake to less than 15% of total calories and eliminating alcohol consumption, as recommended by the 2021 ACC expert consensus decision pathway 1. The management of severe hypertriglyceridemia involves a multifaceted approach, including:
- Dietary modifications: restricting fat intake to less than 15% of total calories, eliminating alcohol consumption, and reducing added sugars 1
- Lifestyle changes: addressing underlying causes such as diabetes, hypothyroidism, or genetic disorders 1
- Medication therapy: first-line medications include fibrates, such as fenofibrate (145 mg daily) or gemfibrozil (600 mg twice daily), which can reduce triglycerides by 30-50% 1
- Omega-3 fatty acids (2-4 grams daily) are also effective and can be used alone or in combination with fibrates 1
- For extremely high levels (>2000 mg/dL), consider adding niacin (starting at 500 mg daily, gradually increasing to 1-2 grams daily) or prescription omega-3 fatty acids like icosapent ethyl (2 grams twice daily) 1 The goal of treatment is to reduce triglyceride levels, prevent acute pancreatitis, and address underlying causes, with regular monitoring of triglyceride levels every 4-6 weeks until stabilized, as recommended by the 2021 ACC expert consensus decision pathway 1. Key considerations in the management of severe hypertriglyceridemia include:
- Identifying and addressing secondary causes of hypertriglyceridemia 1
- Implementing a very-low-fat diet (10% to 15% of calories) for patients with severe hypertriglyceridemia 1
- Using pharmacotherapy to lower triglyceride levels, with the effectiveness of pharmacotherapy limited when triglycerides are >1000 mg/dL 1
From the FDA Drug Label
Fenofibrate tablets are also indicated as adjunctive therapy to diet for treatment of adult patients with severe hypertriglyceridemia. Niacin is also indicated as adjunctive therapy for treatment of adult patients with severe hypertriglyceridemia who present a risk of pancreatitis and who do not respond adequately to a determined dietary effort to control them
To treat severe hypertriglyceridemia, fenofibrate or niacin can be used as adjunctive therapy to diet.
- Fenofibrate is indicated for adult patients with severe hypertriglyceridemia.
- Niacin is indicated for adult patients with severe hypertriglyceridemia who are at risk of pancreatitis and do not respond to dietary efforts. The dosage of niacin should be individualized according to patient response, starting with 500 mg at bedtime and titrating up to a maximum of 2000 mg daily 2. Fenofibrate dosage is not specified in the provided label for severe hypertriglyceridemia, but it is indicated as adjunctive therapy to diet 3.
From the Research
Treatment Options for Severe Hypertriglyceridemia
- Fibrates are considered the first-line treatment for patients with severe hypertriglyceridemia 4
- Omega-3 fatty acids and niacin are also useful drugs for patients with hypertriglyceridemia 4, 5
- Statins in high doses can exhibit significant hypotriglyceridemic activity 4, 5
- Drugs that interfere with chylomicron production, such as orlistat, can be useful for hypertriglyceridemic patients 4
- Gene therapy is under development for patients with known genetic abnormalities of triglyceride metabolism 4
Hospitalization and Emergency Treatment
- Patients with severe hypertriglyceridemia and abdominal pain or pancreatitis should be hospitalized and treated with hypolipidemic drugs and, if needed, with insulin/dextrose infusion or therapeutic apheresis 4
- Aggressive continuous intravenous insulin can be used to lower triglycerides and prevent complications of pancreatitis 6
- The median time to triglyceride level less than 1000 mg/dL and 500 mg/dL was 45 hours (1.8 days) and 75 hours (3.1 days) respectively, with a weight-based insulin infusion 6
Management and Lifestyle Modifications
- Correcting secondary causes of hypertriglyceridemia, such as obesity, uncontrolled diabetes, alcohol misuse, and various commonly used drugs, is important before starting drug treatment 7
- Optimizing lifestyle choices, including dietary modification, is crucial in managing hypertriglyceridemia 7
- A step-by-step management strategy can be adopted, including non-drug approaches and drug treatment, to reduce the risk of pancreatitis and cardiovascular disease 7