What is the best medication to treat hypertriglyceridemia (elevated triglycerides) with mildly elevated low-density lipoprotein (LDL) cholesterol and low high-density lipoprotein (HDL) cholesterol?

From the Guidelines

For patients with hypertriglyceridemia accompanied by mildly elevated LDL and low HDL cholesterol, fibrates are the first-line treatment, especially in patients at risk of pancreatitis, as recommended by the Endocrine Society guidelines 1. 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.

• Fibrates, such as fenofibrate (48-145 mg daily), are effective in reducing triglyceride levels and can be used alone or in combination with other medications.
• Niacin and n-3 fatty acids can also be considered in patients with moderate to severe hypertriglyceridemia, as they have been shown to be beneficial in reducing triglyceride levels and improving cardiovascular risk factors 1.
• Statins have a modest triglyceride-lowering effect (typically 10% to 15%) and may be useful to modify cardiovascular risk in patients with moderately elevated triglyceride levels, but they should not be used alone in patients with severe or very severe hypertriglyceridemia 1. Some key points to consider when treating patients with hypertriglyceridemia include:
• Evaluating patients for family history of dyslipidemia and cardiovascular disease, as well as assessing for other cardiovascular risk factors, such as central obesity, hypertension, abnormal glucose metabolism, and liver dysfunction 1.
• Implementing lifestyle modifications, including dietary counseling, weight loss, and increased physical activity, to help reduce triglyceride levels and improve overall cardiovascular health 1.
• Monitoring patients for potential side effects and drug interactions, particularly when using combination therapy, and adjusting treatment as needed to minimize risks and maximize benefits 1.

From the FDA Drug Label

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. Fenofibrate tablets are also indicated as adjunctive therapy to diet for treatment of adult patients with severe hypertriglyceridemia.

The best medication to treat hypertriglyceridemia with mildly elevated LDL cholesterol and low HDL cholesterol is fenofibrate.

• Fenofibrate has been shown to lower triglycerides, LDL-C, and Total-C, and raise HDL-C in patients with primary hypercholesterolemia or mixed dyslipidemia 2.
• Fenofibrate is also indicated for the treatment of adult patients with severe hypertriglyceridemia 2.
• It is essential to note that fenofibrate should be used as an adjunctive therapy to diet to reduce elevated lipid levels.

From the Research

Treatment Options for Hypertriglyceridemia

To address the issue of elevated triglycerides (382 mg/dL) with mildly elevated low-density lipoprotein (LDL) cholesterol and low high-density lipoprotein (HDL) cholesterol, several medication options can be considered:

• Statins: These are the first line of therapy for managing mild to moderate hypertriglyceridemia and can reduce mean triglyceride levels by up to 18% 3.
• Fibrates: These can be used as second-line agents to lower serum triglyceride levels and raise HDL cholesterol, with modest effects on LDL cholesterol 4.
• Niacin: This is the most potent HDL-increasing drug currently available and can also lower triglycerides and LDL cholesterol 5.
• Long-chain omega-3 fatty acids: These may be a well-tolerated and effective alternative to fibrates and niacin for reducing triglyceride levels 3.
• Combination therapy: Statin + fibrate therapy can be considered for high-risk patients with mixed hyperlipidemia, but requires careful monitoring of liver function and creatine kinase 6.

Considerations for Medication Selection

When selecting a medication, the following factors should be considered:

• The patient's individual lipid profile and cardiovascular risk factors
• The potential benefits and risks of each medication, including adverse effects and drug-drug interactions
• The need for additional reduction in triglyceride-rich lipoproteins and remnant particles to further reduce residual cardiovascular risk 3
• The availability of large-scale clinical studies to evaluate the effects of each medication on cardiovascular outcomes and risk reduction 3, 7, 5