What is the first-line drug for hypertriglyceridemia?

From the Guidelines

Fibrates are the first-line treatment for patients with hypertriglyceridemia who are at risk of pancreatitis. According to the Endocrine Society guidelines released in 2013 1, fibrates are the recommended initial pharmacotherapy for managing hypertriglyceridemia, particularly in patients at risk of pancreatitis.

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, as well as reduced intake of dietary fat and simple carbohydrates 1.
• Fibrates work by activating peroxisome proliferator-activated receptors (PPARs), which increase lipoprotein lipase activity and reduce hepatic triglyceride production, effectively lowering triglyceride levels in the blood.

Implementation and Alternatives

• For immediate implementation, patients should be advised to take the medication consistently and with meals as directed, with full effects potentially not seen for several weeks 1.
• If fibrates are contraindicated or poorly tolerated, omega-3 fatty acids or niacin may be considered as alternative first-line treatments, depending on the severity of hypertriglyceridemia and individual patient factors 1.
• Patients should also be counseled on lifestyle modifications such as reducing intake of refined carbohydrates and saturated fats, increasing physical activity, and maintaining a healthy weight, as these can significantly impact triglyceride levels.

From the FDA Drug Label

The initial treatment for dyslipidemia is dietary therapy specific for the type of lipoprotein abnormality. Excess body weight and excess alcoholic intake may be important factors in hypertriglyceridemia and should be addressed prior to any drug therapy.

The first-line treatment for hypertriglyceridemia is dietary therapy, not a specific drug.

• Dietary changes and lifestyle modifications are recommended before initiating any drug therapy.
• There is no mention of a specific first-line drug for hypertriglyceridemia in the provided drug label 2.

From the Research

First-Line Treatment for Hypertriglyceridemia

• The first-line drug for hypertriglyceridemia is statins, which primarily target elevated low-density lipoprotein cholesterol levels but also reduce mean triglyceride levels by up to 18% 3.
• Statins are recommended for the management of mild to moderate hypertriglyceridemia (1.7-5.6 mmol/L [150-499 mg/dL]) 3, 4.
• For patients with high triglyceride levels who have borderline or intermediate risk, statins can be considered 4.
• In cases of severe hypertriglyceridemia (≥5.6 mmol/L [≥500 mg/dL]), immediate use of triglyceride-lowering agents such as fibrates, niacin, or long-chain omega-3 fatty acids may be necessary 3, 4.

Alternative Treatments

• Fibrates, such as fenofibrate, are effective in lowering triglyceride levels and increasing high-density lipoprotein cholesterol levels 5, 6, 7.
• Omega-3 fatty acids may be a well-tolerated and effective alternative to fibrates and niacin for reducing triglyceride levels 3, 5.
• Niacin can also be considered for patients with severely elevated triglyceride levels to reduce the risk of pancreatitis 3, 4.