What are the guidelines to lower hypertriglyceridemia?

From the Guidelines

To lower hypertriglyceridemia, lifestyle modifications are the cornerstone of treatment, including weight loss, regular physical activity, and dietary changes, as recommended by the most recent guidelines 1.

Key Lifestyle Modifications

• Aim for 150 minutes of moderate-intensity exercise weekly
• Reduce intake of simple carbohydrates, especially added sugars and alcohol
• Dietary fat should be modified to include more omega-3 fatty acids from fatty fish while limiting saturated and trans fats

Medications for Hypertriglyceridemia

For triglyceride levels above 500 mg/dL, medications are typically recommended.

• Fibrates like fenofibrate (145 mg daily) or gemfibrozil (600 mg twice daily) are first-line pharmacological options
• Omega-3 fatty acid supplements (2-4 grams daily) are also effective, as shown in the REDUCE-IT trial 1
• Statins may be added if LDL cholesterol is also elevated
• Niacin (1-2 grams daily) can be considered but has more side effects

Special Considerations

• For very high triglycerides (>1000 mg/dL), immediate dietary fat restriction is crucial to prevent acute pancreatitis
• Regular monitoring of triglyceride levels is important to assess treatment effectiveness, with a goal of bringing levels below 150 mg/dL
• The addition of icosapent ethyl can be considered to reduce cardiovascular risk in individuals with ASCVD or other cardiovascular risk factors on a statin with managed LDL cholesterol but elevated triglycerides (150–499 mg/dL) 1

From the FDA Drug Label

To reduce elevated TC, LDL-C, Apo B and TG, and to increase HDL-C in patients with primary hyperlipidemia and mixed dyslipidemia. To reduce TG in adult patients with severe hypertriglyceridemia. 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. Physical exercise can be an important ancillary measure Diseases contributory to hyperlipidemia, such as hypothyroidism or diabetes mellitus should be looked for and adequately treated.

The guidelines to lower hypertriglyceridemia include:

• Dietary therapy specific for the type of lipoprotein abnormality
• Addressing excess body weight and alcoholic intake
• Physical exercise as an ancillary measure
• Treating contributory diseases such as hypothyroidism or diabetes mellitus
• Medications such as fenofibrate or niacin may be used as adjunctive therapy to diet 2, 3. Key considerations:
• Dose and administration: Fenofibrate tablets should be given with meals, and the initial dose is 54 mg per day to 160 mg per day for severe hypertriglyceridemia 2.
• Niacin extended-release tablets should be taken at bedtime with a low-fat snack, and the dose range is 500 mg to 2000 mg once daily 3.

From the Research

Guidelines to Lower Hypertriglyceridemia

To manage hypertriglyceridemia, several guidelines and treatment options are available. The primary goal is to reduce triglyceride levels and decrease the risk of cardiovascular disease (CVD) and acute pancreatitis.

Treatment Options

• Statins are the first line of therapy for mild to moderate hypertriglyceridemia (1.7-5.6 mmol/L [150-499 mg/dL]), as they primarily target elevated low-density lipoprotein cholesterol levels and can reduce mean triglyceride levels by up to 18% 4.
• For severe hypertriglyceridemia (≥5.6 mmol/L [≥500 mg/dL]), guidelines recommend the immediate use of triglyceride-lowering agents such as fibrates, niacin, or long-chain omega-3 fatty acids 4.
• The addition of fibrates, niacin, or long-chain omega-3 fatty acids to statin therapy may be necessary for individuals with persistent elevated triglyceride or non-high-density lipoprotein cholesterol levels despite high-intensity statin therapy 4, 5.
• Prescription omega-3 fatty acids (P-OM3) have been shown to be effective in reducing triglyceride levels, with a study demonstrating a 60.8% reduction in median triglyceride values when used in combination with fenofibrate 6.
• Omega-3 fatty acids with EPA+DHA or EPA-only have been found to be roughly comparable for triglyceride lowering and do not increase low-density lipoprotein cholesterol when used as monotherapy or in combination with a statin 7.

Dietary Measures

• Dietary treatment to lower cholesterol and triglyceride levels and reduce cardiovascular risk includes minimizing saturated fats and refined carbohydrates, eliminating trans-fat, and increasing fruits, vegetables, whole grains, low-fat dairy, and fish or other omega-3 fatty acids 8.
• Adhering to a Mediterranean diet is strongly recommended due to its ability to lower CVD and total mortality 8.
• High-dose omega-3 fatty acids have been found to lower triglyceride levels, reduce CVD, and prevent coronary plaque progression 8.