What is the management for hypertriglyceridemia (elevated triglycerides)?

From the Guidelines

Lifestyle interventions, including dietary changes and weight loss, are the first line of therapy for managing hypertriglyceridemia, as recommended by the 2021 ACC expert consensus decision pathway 1. The management of hypertriglyceridemia involves a multifaceted approach that prioritizes lifestyle modifications and, when necessary, pharmacological interventions.

Key Lifestyle Interventions

• Dietary changes: reducing intake of simple carbohydrates, alcohol, and saturated fats, while increasing consumption of omega-3 fatty acids, fiber, and plant sterols.
• Weight loss: aiming for a 5-10% reduction in body weight for overweight individuals, as this can lead to a significant decrease in triglyceride levels, with studies indicating a 20% decrease in triglycerides for every 5-10% of body weight lost 1.
• Regular aerobic exercise: at least 150 minutes weekly, to help manage weight and improve lipid profiles.

Pharmacological Interventions

For moderate to severe hypertriglyceridemia, medications may be necessary alongside lifestyle changes.

• Fibrates, such as fenofibrate or gemfibrozil, are considered first-line medications for managing severe hypertriglyceridemia, especially in patients at risk of pancreatitis 1.
• Omega-3 fatty acids can also be effective in lowering triglyceride levels and may be used in conjunction with other medications.
• Statins, such as atorvastatin or rosuvastatin, may be added to the treatment regimen, particularly in patients with concurrent LDL elevation or increased cardiovascular risk, as they have been shown to modestly lower triglyceride levels and significantly reduce cardiovascular events 1.

Special Considerations

• For very severe cases of hypertriglyceridemia (>1000 mg/dL), immediate dietary fat restriction and fibrate therapy are crucial to prevent acute pancreatitis.
• The treatment goal is not only to lower triglyceride levels but also to reduce the risk of cardiovascular disease and pancreatitis, emphasizing the importance of a comprehensive management plan that includes lifestyle modifications and, when necessary, pharmacological interventions.

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.

Patients should be placed on an appropriate lipid-lowering diet before receiving fenofibrate tablets and should continue this diet during treatment with fenofibrate tablets.

For a patient with elevated triglycerides of 3.06 (assuming units are mmol/L, but the unit is not specified), dietary therapy should be the initial approach, focusing on a lipid-lowering diet. Additionally, factors such as excess body weight and alcoholic intake should be addressed. If drug therapy is considered necessary, fenofibrate could be an option, with the initial dose depending on the specific condition being treated, such as primary hypercholesterolemia or mixed dyslipidemia, or severe hypertriglyceridemia, as outlined in the dosing guidelines 2. However, the decision to start fenofibrate should be based on a comprehensive assessment of the patient's condition and response to initial dietary and lifestyle modifications.

From the Research

Management for Hypertriglyceridemia

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

• For patients with mild to moderate hypertriglyceridemia (1.7-5.6 mmol/L [150-499 mg/dL]), statins are the first line of therapy, as they can reduce mean triglyceride levels by up to 18% 3.
• In patients with severe hypertriglyceridemia (≥5.6 mmol/L [≥500 mg/dL]), immediate use of triglyceride-lowering agents is recommended 3.
• Additional agents such as fibrates, niacin, or long-chain omega-3 fatty acids may be added to statin therapy if elevated triglyceride or non-high-density lipoprotein cholesterol levels persist 3, 4.
• Omega-3 fatty acids have been shown to be effective in reducing triglyceride levels and may be a well-tolerated alternative to fibrates and niacin 3, 5.
• A recent trial with an omega-3 fatty acid, icosapent-ethyl, provided evidence for a 25% reduction in ASCVD events in statin-treated high-risk population 6.

Treatment Options

• Statins: first line of therapy for mild to moderate hypertriglyceridemia 3.
• Fibrates: may be added to statin therapy if elevated triglyceride or non-high-density lipoprotein cholesterol levels persist 3, 4.
• Niacin: may be added to statin therapy if elevated triglyceride or non-high-density lipoprotein cholesterol levels persist 3, 4.
• Omega-3 fatty acids: effective in reducing triglyceride levels and may be a well-tolerated alternative to fibrates and niacin 3, 5.
• Icosapent-ethyl: provided evidence for a 25% reduction in ASCVD events in statin-treated high-risk population 6.

Specific Considerations

• For patients with very high triglycerides, lifestyle measures and several triglyceride-lowering agents are indicated, often in combination, to prevent episodes of pancreatitis 6.
• A novel Apo C-III inhibitor may provide additional benefit in patients with very high triglycerides 6.
• The use of omega-3 fatty acids (4 g/d) for improving atherosclerotic cardiovascular disease risk in patients with hypertriglyceridemia is supported by a 25% reduction in major adverse cardiovascular events in REDUCE-IT 5.