What is the treatment for Hypertriglyceridemia?

From the Guidelines

Hypertriglyceridemia treatment should begin with lifestyle modifications for all patients, including weight loss, regular exercise, limiting alcohol intake, and adopting a low-carbohydrate, low-fat diet, as recommended by the 2021 ACC expert consensus decision pathway 1. The goal of treatment is to reduce the risk of acute pancreatitis and cardiovascular events.

• Lifestyle modifications are the first line of therapy, with a focus on weight loss, as a 5% to 10% reduction in body weight is associated with a 20% decrease in triglycerides 1.
• For triglyceride levels above 500 mg/dL, medication therapy is typically recommended, with first-line pharmacological treatment including fibrates such as fenofibrate or gemfibrozil, 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, as demonstrated by the Reduction of Cardiovascular Events with Icosapent Ethyl–Intervention Trial (REDUCE-IT) 1.
• In patients with concurrent high LDL cholesterol, statins like atorvastatin or rosuvastatin may be added to reduce the risk of cardiovascular events 1.
• Regular monitoring of lipid levels every 3-6 months is essential to assess treatment efficacy and adjust therapy as needed. Key considerations in treatment include:
• The cause of hypertriglyceridemia is often multifactorial, and therapy should be individualized to target the lifestyle triggers that are thought to be the greatest contributors to hypertriglyceridemia 1.
• Severe hypertriglyceridemia (>1000 mg/dL) may warrant immediate fasting and possibly hospitalization to reduce the risk of acute pancreatitis 1.

From the FDA Drug Label

Fenofibrate tablets are also 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. The effect of fenofibrate on serum triglycerides were studied in two randomized, double-blind, placebo-controlled clinical trials of 147 hypertriglyceridemic patients

Treatment of Hypertriglyceridemia:

• Fenofibrate is indicated as adjunctive therapy to diet for the treatment of adult patients with severe hypertriglyceridemia.
• The initial dose of fenofibrate for severe hypertriglyceridemia is 54 mg per day to 160 mg per day.
• Dosage should be individualized according to patient response and adjusted as necessary following repeat lipid determinations at 4 to 8 week intervals.
• The maximum dose is 160 mg once daily 2.
• In clinical trials, fenofibrate decreased primarily very low density lipoprotein (VLDL) triglycerides and VLDL cholesterol in patients with hypertriglyceridemia 2.

From the Research

Hypertriglyceridemia Treatment Options

• 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.
• 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, and a single large-scale randomized, blinded trial has shown the efficacy of 4 g of eicosapentaenoic acid ethyl ester per day in lowering the risk in high-risk patients 3.

Pharmacological Treatment

• Statins are usually the first line of therapy for the management of mild to moderate hypertriglyceridemia, and can reduce mean triglyceride levels by up to 18% 4.
• Fibrates, niacin, or long-chain omega-3 fatty acids may be added if elevated triglyceride or non-high-density lipoprotein cholesterol levels persist despite the use of high-intensity statin therapy 4.
• Fibrates are currently the drugs of choice for hypertriglyceridemia, frequently in combination with statins 5.
• Niacin and omega-3 fatty acids can improve control of triglyceride levels when other measures are inadequately effective 5.

Management Strategies

• Calculating a patient's 10-year risk of atherosclerotic cardiovascular disease is pertinent to determine the role of medications 6.
• 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 6.
• Patients with severely elevated triglyceride levels should be considered for treatment with fibrates, omega-3 fatty acids, or niacin to reduce the risk of pancreatitis 6.
• Correcting secondary causes, such as obesity, uncontrolled diabetes, alcohol misuse, and optimizing lifestyle choices, is important before starting drug treatment 7.