From the Guidelines
Fibrates are the first-line treatment for patients with hypertriglyceridemia who are at risk of pancreatitis, as they can reduce triglyceride levels by 30-50%. Medications for elevated triglycerides include fibrates, omega-3 fatty acids, statins, and niacin. Fibrates like fenofibrate (145mg daily) or gemfibrozil (600mg twice daily) are often used for severely elevated triglycerides (>500 mg/dL) 1. Prescription-strength omega-3 fatty acids such as icosapent ethyl (2g twice daily) or omega-3 ethyl esters (2-4g daily) are also effective and have fewer side effects than other medications. Statins like atorvastatin (10-80mg daily) or rosuvastatin (5-40mg daily) are typically used when triglycerides are moderately elevated (200-500 mg/dL) and accompanied by high LDL cholesterol 1. Niacin (1-2g daily) can lower triglycerides by 20-50% but has more side effects including flushing and potential liver issues.
Key Considerations
- 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.
- Initial treatment of patients with mild to moderate hypertriglyceridemia should include dietary counseling and weight loss in patients who are overweight or obese.
- For patients with severe to very severe hypertriglyceridemia, reduced intake of dietary fat and simple carbohydrates is recommended, in combination with drug treatment to reduce the risk of pancreatitis 1.
- Lifestyle modifications should accompany medication therapy, including reducing alcohol and sugar intake, increasing physical activity, and consuming a diet rich in fiber and healthy fats.
- Treatment should continue long-term with regular monitoring of lipid levels and liver function 1.
From the FDA Drug Label
Fenofibric acid is eliminated with a half-life of 20 hours, allowing once daily dosing. The medication fenofibrate is used for elevated triglycerides.
- Key points:
- Fenofibrate is used to treat high triglycerides.
- The dosage regimen can be used in elderly patients with normal renal function.
- Patients with severe renal impairment should avoid using fenofibrate.
- Dose reduction is required in patients with mild to moderate renal impairment. 2
From the Research
Medication Options for Elevated 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
- Omega-3 fatty acids: can be used to lower triglyceride levels, especially in patients with hypertriglyceridemia 4, 5, 6
- Niacin: can be considered for patients with severely elevated triglyceride levels to reduce the risk of pancreatitis, and is also effective in increasing HDL cholesterol and lowering triglycerides and LDL cholesterol 4, 7
Comparison of Medication Options
- Omega-3 fatty acids and fenofibrate have been compared in a head-to-head study, which found that fenofibrate had better effects on lipoprotein and metabolic profiles in patients with hypertriglyceridemia 6
- Statins, fibrates, and niacin have been shown to have different effects on lipid profiles and cardiovascular outcomes, and the choice of medication should be based on the individual patient's risk factors and lipid profile 7
Treatment Guidelines
- The American Heart Association recommends the use of omega-3 fatty acids for the management of hypertriglyceridemia, especially in patients with very high triglyceride levels 5
- Guidelines for the management of severe hypertriglyceridemia recommend the immediate use of triglyceride-lowering agents, while statins remain the first line of therapy for the management of mild to moderate hypertriglyceridemia 4