What is the management for hypertriglyceridemia?

From the Guidelines

Management of hypertriglyceridemia involves both lifestyle modifications and pharmacological interventions, with the primary goal of reducing morbidity, mortality, and improving quality of life. The most recent and highest quality study, 1, published in 2021, provides guidance on the management of hypertriglyceridemia. Key components of lifestyle modifications include:

• Dietary changes, such as reducing intake of simple carbohydrates, saturated fats, and alcohol
• Increasing consumption of omega-3 fatty acids, fiber, and plant sterols
• Weight loss for overweight individuals
• Regular exercise, at least 150 minutes of moderate activity weekly
• Strict glycemic control for diabetic patients For pharmacotherapy, the following are recommended:
• Statins for moderate elevations (150-499 mg/dL), particularly when LDL cholesterol is also elevated
• Fibrates, such as fenofibrate (145 mg daily) or gemfibrozil (600 mg twice daily), for severe hypertriglyceridemia (≥500 mg/dL) to reduce pancreatitis risk
• Prescription omega-3 fatty acids, such as icosapent ethyl (2g twice daily) or omega-3 ethyl esters (2-4g daily), as effective adjuncts
• Niacin (1-2g daily) may be considered, but has more side effects It is essential to monitor treatment efficacy with lipid panels every 4-12 weeks initially, then every 3-12 months once stable, as recommended by 1 and 1. Additionally, identifying and treating underlying causes of elevated triglycerides, such as lifestyle causes, secondary disorders, and triglyceride-raising drugs, is crucial, as highlighted in 1. Overall, a comprehensive approach addressing lifestyle modifications and pharmacological interventions can effectively manage hypertriglyceridemia, reducing the risk of pancreatitis and improving cardiovascular outcomes, as supported by 1 and 1.

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. Fenofibrate tablets are 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 management for hypertriglyceridemia includes:

• Dietary therapy: specific for the type of lipoprotein abnormality
• Lifestyle modifications: addressing excess body weight and excess alcoholic intake
• Fenofibrate therapy: as adjunctive therapy to diet, with an initial dose of 54 mg per day to 160 mg per day, individualized according to patient response 2
• Monitoring and adjustment: of dosage based on lipid levels, with consideration of reducing the dosage if lipid levels fall significantly below the targeted range 2

From the Research

Management of Hypertriglyceridemia

The management of hypertriglyceridemia involves a combination of lifestyle modifications and pharmacological interventions.

• 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 levels 3.
• Calculating a patient's 10-year risk of atherosclerotic cardiovascular disease is pertinent to determine the role of medications 4.
• For patients with high triglyceride levels, statins can be considered, especially those with borderline or intermediate risk 4.
• Fibrates, omega-3 fatty acids, or niacin can be considered for patients with severely elevated triglyceride levels to reduce the risk of pancreatitis 4, 5.
• Omega-3 fatty acids, particularly eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), have been shown to be effective in reducing triglyceride levels and improving cardiovascular outcomes 6.

Pharmacological Interventions

• Statins are the first line of therapy for the management of mild to moderate hypertriglyceridemia, as they primarily target elevated low-density lipoprotein cholesterol levels and also reduce mean triglyceride levels 5, 7.
• Fibrates, niacin, and omega-3 fatty acids can be added to statin therapy if elevated triglyceride or non-high-density lipoprotein cholesterol levels persist 5, 7.
• Prescription omega-3 fatty acids (EPA+DHA or EPA-only) at a dose of 4 g/d are an effective and safe option for reducing triglycerides as monotherapy or as an adjunct to other lipid-lowering agents 6.

Special Considerations

• Patients with severely elevated triglyceride levels (≥500 mg/dL) are at increased risk of pancreatitis and may require immediate use of triglyceride-lowering agents 5.
• Patients with acute pancreatitis associated with hypertriglyceridemia may require insulin infusion and plasmapheresis if triglyceride levels remain elevated despite conservative management 4.
• Patients with purely genetic types of hypertriglyceridemia, such as familial chylomicronemia syndrome, should be treated in specialized outpatient clinics 3.