From the Guidelines
Fibrates, such as fenofibrate 145mg daily, are the first-line treatment for patients with hypertriglyceridemia who are at risk of pancreatitis, as recommended by the most recent guidelines 1. Medications commonly prescribed for high triglycerides include fibrates, omega-3 fatty acids (2-4g daily), statins (like atorvastatin 10-80mg daily or rosuvastatin 5-40mg daily), and niacin (500-2000mg daily). Treatment typically begins with lifestyle modifications including a low-carbohydrate diet, regular exercise, weight loss, limiting alcohol, and avoiding sugary foods. If triglycerides exceed 500 mg/dL, medication is usually recommended to reduce the risk of pancreatitis. For levels between 200-499 mg/dL, treatment focuses on lowering LDL cholesterol first, then addressing triglycerides if they remain elevated. Medications work through different mechanisms: fibrates enhance triglyceride breakdown, omega-3 fatty acids reduce triglyceride production in the liver, statins inhibit cholesterol synthesis, and niacin decreases triglyceride production. Some key points to consider when choosing a medication include:
- The patient's triglyceride level and risk of pancreatitis
- The presence of other lipid abnormalities, such as high LDL cholesterol or low HDL cholesterol
- The patient's medical history and potential drug interactions
- The need for regular monitoring of lipid levels and liver function. The specific medication choice depends on these individual patient factors, as well as the most recent clinical guidelines 1.
From the FDA Drug Label
Fenofibrate tablets are indicated as adjunctive therapy to diet to reduce elevated ... Triglycerides ... in adult patients with primary hypercholesterolemia or mixed dyslipidemia. Fenofibrate tablets are also indicated as adjunctive therapy to diet for treatment of adult patients with severe hypertriglyceridemia.
Medication for high triglycerides: Fenofibrate is used as an adjunct to diet to reduce triglycerides in adult patients with primary hypercholesterolemia or mixed dyslipidemia, and for the treatment of severe hypertriglyceridemia.
- The initial dose for severe hypertriglyceridemia is 54 mg per day to 160 mg per day, and should be individualized according to patient response 2.
From the Research
Medication Options for High Triglycerides
- Statins: can be considered for patients with high triglyceride levels who have borderline or intermediate risk of atherosclerotic cardiovascular disease 3
- 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
- Fibrates: can be considered for patients with severely elevated triglyceride levels to reduce the risk of pancreatitis 3, 4, 5
- Omega-3 fatty acids: can be used to lower triglyceride levels, especially in patients with very high triglyceride levels 4, 5
- Niacin: can be considered for patients with severely elevated triglyceride levels to reduce the risk of pancreatitis 3, 4, 5
Treatment Approach
- The treatment approach for high triglycerides depends on the level of triglycerides and the patient's risk of atherosclerotic cardiovascular disease 3, 6
- For patients with mild-to-moderate hypertriglyceridemia, statins are usually the first-line treatment 6
- For patients with severely elevated triglyceride levels, fibrates, omega-3 fatty acids, or niacin may be considered to reduce the risk of pancreatitis 3, 4, 5
Dosage and Efficacy
- The total EPA and DHA dose recommended for triglyceride lowering is approximately 2-4 g/day 4
- Prescription omega-3 fatty acids can reduce triglyceride levels by 45% and very low-density lipoprotein cholesterol levels by more than 50% in patients with triglyceride levels above 500 mg/dl 4
- High-dose icosapent can reduce cardiovascular mortality in patients at high risk who continue to have high triglyceride levels despite statin use, with a number needed to treat of 111 to prevent one cardiovascular death over five years 3