What is the best management approach for a patient with significantly elevated triglycerides and low HDL (high-density lipoprotein) cholesterol?

From the Guidelines

The best management approach for a patient with significantly elevated triglycerides and low HDL cholesterol involves a combination of lifestyle modifications and pharmacotherapy, with a focus on lifestyle changes as the initial step, as recommended by the most recent guidelines 1. The patient's lab results show a total cholesterol level of 174 mg/dL, triglycerides of 435 mg/dL, HDL cholesterol of 26 mg/dL, and LDL cholesterol of 78 mg/dL. Given the significantly elevated triglycerides and low HDL cholesterol, the following management approach is recommended:

• Lifestyle modifications, including:
  • A Mediterranean diet or Dietary Approaches to Stop Hypertension (DASH) dietary pattern, as recommended by the 2019 guidelines 1
  • Reduction of saturated fat and trans fat
  • Increase of dietary n-3 fatty acids, viscous fiber, and plant stanols/sterols intake
  • Increased physical activity
• Pharmacological management, including:
  • Fibrates, such as fenofibrate, as first-line medications for severe hypertriglyceridemia, as recommended by the 2013 guidelines 1
  • Statins, such as atorvastatin or rosuvastatin, for moderate elevations, particularly if LDL cholesterol is also elevated
  • Omega-3 fatty acids as adjunctive therapy
  • Niacin (extended-release) to raise HDL while lowering triglycerides, but with caution due to potential side effects The patient's young age and lack of other cardiovascular risk factors should be taken into consideration when determining the best management approach. Regular monitoring of lipid levels every 3-6 months is recommended to assess treatment efficacy, as suggested by the 2015 guidelines 1. The goal of treatment is to reduce the risk of developing atherosclerotic cardiovascular disease, and lifestyle modifications should be the foundation of the management approach, with pharmacotherapy added as needed, as recommended by the most recent guidelines 1.

From the FDA Drug Label

1 INDICATIONS AND USAGE

1. 1 Primary Hypercholesterolemia or Mixed Dyslipidemia Fenofibrate tablets are indicated as adjunctive therapy to diet to reduce elevated low-density lipoprotein cholesterol (LDL-C), total cholesterol (Total-C), Triglycerides and apolipoprotein B (Apo B), and to increase high-density lipoprotein cholesterol (HDL-C) in adult patients with primary hypercholesterolemia or mixed dyslipidemia.

14 CLINICAL STUDIES

1. 1 Primary Hypercholesterolemia (Heterozygous Familial and Nonfamilial) and Mixed Dyslipidemia The effects of fenofibrate at a dose equivalent to 160 mg fenofibrate tablets per day were assessed from four randomized, placebo-controlled, double-blind, parallel-group studies including patients with the following mean baseline lipid values: total-C 306.9 mg/dL; LDL-C 213.8 mg/dL; HDL-C 52. 3 mg/dL; and triglycerides 191 mg/dL. Fenofibrate therapy lowered LDL-C, Total-C, and the LDL-C/HDL-C ratio. Fenofibrate therapy also lowered triglycerides and raised HDL-C (see Table 4).

The patient has elevated triglycerides (435 mg/dL) and low HDL cholesterol (26 mg/dL).

• Fenofibrate may be considered as an adjunct to diet for the treatment of adult patients with severe hypertriglyceridemia.
• The patient's triglyceride level is significantly elevated, and fenofibrate has been shown to lower triglycerides in clinical trials 2.
• However, it is essential to note that fenofibrate may increase LDL-C in some patients, and the effect of fenofibrate on cardiovascular morbidity and mortality has not been determined 2.
• The patient should be advised to follow an appropriate lipid-modifying diet while taking fenofibrate and to return to their physician's office for routine monitoring 2.

From the Research

Patient Profile

• 19-year-old male of Middle Eastern heritage
• Lab results:
  • Total Cholesterol: 174 mg/dL (high)
  • Triglycerides: 435 mg/dL (high)
  • HDL Cholesterol: 26 mg/dL (low)
  • VLDL Cholesterol: 70 mg/dL (high)
  • LDL Cholesterol: 78 mg/dL (within normal range)

Management Approach

• Lifestyle modifications are first-line therapy for patients with elevated triglycerides and low HDL cholesterol 3
• A moderately reduced-calorie diet, increased physical activity, and behavior strategies can facilitate adherence to a healthy lifestyle 3
• Physical activity should be encouraged, with a goal of at least 150-300 minutes/week of moderate-intensity aerobic activity 4
• Omega-3 fatty acid therapies, particularly eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), can effectively reduce triglyceride levels 5, 6, 7
• Prescription formulations of omega-3 fatty acids, such as icosapent ethyl (Vascepa), can lower triglyceride levels without increasing LDL cholesterol levels 5, 6

Treatment Options

• Lifestyle modifications:
  • Dietary changes: reduced-calorie diet, increased omega-3 fatty acid intake
  • Increased physical activity: at least 150-300 minutes/week of moderate-intensity aerobic activity
  • Behavior strategies: motivational interviewing, cognitive behavior therapy, removal of environmental trigger foods
• Pharmacological interventions:
  • Omega-3 fatty acid therapies: prescription formulations such as icosapent ethyl (Vascepa)
  • Other lipid-lowering medications: may be considered if lifestyle modifications and omega-3 fatty acid therapies are insufficient to achieve desired lipid levels

Considerations

• Patient's age, ethnicity, and medical history should be taken into account when developing a management plan
• Regular monitoring of lipid levels and other cardiovascular risk factors is necessary to assess the effectiveness of the management plan and make adjustments as needed 4, 5, 6, 7