What are the treatment options for managing high triglycerides?

From the Guidelines

Lifestyle modifications and medications are essential for managing high triglycerides, with the primary goal of reducing the risk of cardiovascular disease and pancreatitis. The most recent and highest quality study, 1, emphasizes the importance of lifestyle interventions as the first line of therapy for managing persistent hypertriglyceridemia.

Lifestyle Modifications

Key lifestyle changes include:

• Reducing intake of refined carbohydrates, sugar, and alcohol
• Increasing physical activity to at least 150 minutes of moderate exercise weekly
• Weight loss of 5-10%, which can significantly reduce triglyceride levels
• Dietary changes to emphasize consuming more omega-3 fatty acids from fatty fish like salmon and sardines, while limiting saturated and trans fats

Medication Options

For medication options, the study 1 suggests that:

• Statins like atorvastatin (10-80 mg daily) or rosuvastatin (5-40 mg daily) are often first-line treatments, especially when LDL cholesterol is also elevated
• Fibrates such as fenofibrate (48-145 mg daily) or gemfibrozil (600 mg twice daily) can reduce triglycerides by 30-50%
• Prescription omega-3 fatty acids (icosapent ethyl 2 grams twice daily or omega-3 ethyl esters 2-4 grams daily) are effective for severe hypertriglyceridemia (>500 mg/dL)
• Niacin (extended-release, 500-2000 mg daily) can lower triglycerides but has more side effects including flushing

Treatment Approach

The treatment approach should be individualized, targeting lifestyle triggers that contribute to hypertriglyceridemia, and monitored with regular lipid panels. According to 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.

Severe Hypertriglyceridemia

For patients with severe hypertriglyceridemia (triglycerides ≥500 mg/dL), therapies should be implemented to reduce excesses in both chylomicrons and VLDL, as suggested by 1. A very rigorous approach to lifestyle interventions, including Medical Nutrition Therapy (MNT), is advised for patients with triglycerides ≥1,000 mg/dL.

Conclusion is not needed, the above is the answer.

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 to reduce elevated... Triglycerides... 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 treatment options for managing high triglycerides include:

• Dietary therapy: specific for the type of lipoprotein abnormality
• Lifestyle modifications: addressing excess body weight and excess alcoholic intake
• Fenofibrate tablets: as adjunctive therapy to diet, to reduce elevated triglycerides in adult patients with primary hypercholesterolemia or mixed dyslipidemia, and for treatment of adult patients with severe hypertriglyceridemia 2
• Monitoring and adjusting treatment: periodically monitoring lipid levels and adjusting the dosage of fenofibrate tablets as necessary 2

From the Research

Treatment Options for Managing High Triglycerides

• 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 (TG) levels 3.
• The need to lower low-density lipoprotein (LDL) concentration must be determined on the basis of cardiovascular risk, independently of the success of lifestyle changes 3.
• Few patients need specific drug treatment to lower TG levels, and fibrates can lower TG concentrations, but their efficacy in combination with statins has not been clearly shown in endpoint studies 3.
• A daily dose of 2-4 g omega-3 fatty acids can also lower TG levels 3, 4.

Medication Options

• Statins can be considered for patients with high triglyceride levels who have borderline or intermediate risk of atherosclerotic cardiovascular disease 5.
• For patients at high risk who continue to have high triglyceride levels despite statin use, high-dose icosapent (purified eicosapentaenoic acid) can reduce cardiovascular mortality 5.
• Fibrates, omega-3 fatty acids, or niacin should be considered for patients with severely elevated triglyceride levels to reduce the risk of pancreatitis 5, 6.
• 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 4.

Combination Therapy

• Concomitant use of prescription omega-3 fatty acids and fenofibrate can result in a greater reduction in triglyceride levels compared to fenofibrate alone 7.
• The addition of prescription omega-3 fatty acids to stable fenofibrate therapy can result in a statistically significant reduction in triglyceride levels 7.