From the Guidelines
The best treatment for elevated triglycerides is a multifaceted approach that includes lifestyle modifications and medication, with the specific treatment depending on the severity of hypertriglyceridemia, as recommended by the most recent guidelines 1.
Overview of Treatment Approach
For mild to moderate elevations (150-499 mg/dL), lifestyle modifications are the first-line approach, including:
- A low-carbohydrate diet
- Weight loss of 5-10% if overweight
- Regular aerobic exercise (150 minutes weekly)
- Limiting alcohol consumption
- Avoiding refined carbohydrates and sugary foods
Medication for Elevated Triglycerides
For triglyceride levels above 500 mg/dL, medication is typically recommended alongside lifestyle changes to reduce the risk of pancreatitis.
- Prescription omega-3 fatty acids (icosapent ethyl 2g twice daily or omega-3 ethyl esters 2-4g daily) are effective and have minimal side effects, as supported by recent guidelines 1.
- Fibrates like fenofibrate (48-145mg daily) or gemfibrozil (600mg twice daily) can reduce triglycerides by 30-50% 1.
- Statins may be added if LDL cholesterol is also elevated, with moderate- or high-intensity statin therapy recommended to reduce the risk of cardiovascular events 1.
- Niacin (1-2g daily) is sometimes used but has more side effects, including flushing and liver concerns.
Severe Hypertriglyceridemia
For very severe hypertriglyceridemia (>1000 mg/dL), a very low-fat diet (<15% of calories) may be temporarily needed, in addition to pharmacologic therapy (fibrin acid derivatives and/or fish oil) to reduce the risk of acute pancreatitis 1.
Monitoring Treatment Effectiveness
Treatment effectiveness should be monitored with lipid panels every 3-6 months, as triglycerides respond to these interventions because they're highly sensitive to dietary carbohydrates, alcohol, and physical activity levels, which all affect the liver's production and clearance of triglyceride-rich lipoproteins.
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 treatment for elevated triglycerides (hypertriglyceridemia) is fenofibrate as an adjunct to diet.
- Key benefits of fenofibrate include:
- Reduction of triglycerides
- Increase of HDL-C
- Reduction of LDL-C and Total-C
- Important considerations:
- Patients should be placed on an appropriate lipid-lowering diet before receiving fenofibrate tablets and should continue this diet during treatment.
- The initial dose of fenofibrate tablet is 160 mg once daily for primary hypercholesterolemia or mixed dyslipidemia, and 54 mg per day to 160 mg per day for severe hypertriglyceridemia.
- 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 maximum dose is 160 mg once daily 2.
From the Research
Treatment Options for Elevated Triglycerides
The treatment for elevated triglycerides, also known as hypertriglyceridemia, involves a combination of lifestyle modifications and pharmacotherapy.
- Lifestyle modifications are the primary intervention for managing triglycerides ≥ 10 mmol/L, including changes in diet, exercise, reduction in body mass index, and abstinence from alcohol consumption 3.
- Therapeutic lifestyle changes (TLC) are the first line of treatment for hypertriglyceridemia, which include a low saturated fat, carbohydrate-controlled diet, combined with alcohol reduction, smoking cessation, and regular aerobic exercise 4.
- High doses of omega-3 fatty acids from fish and fish oil supplements can lower triglyceride levels significantly 4, 5.
Pharmacotherapy
When lifestyle modifications are not sufficient, pharmacotherapy may be necessary.
- Fibrates are initially considered for isolated hypertriglyceridemia 4.
- Statins are preferred when elevated low-density lipoprotein levels accompany hypertriglyceridemia 6, 4.
- Extended release niacin can be considered for patients with low HDL levels and hypertriglyceridemia 4.
- Prescription omega-3 fatty acids can be used as an adjunct to diet for the treatment of very high triglyceride levels 5.
- A formula diet rich in omega-3 fatty acids and medium-chain triglycerides can be used to rapidly decrease plasma triglyceride levels in patients with severe hypertriglyceridemia 7.
Additional Considerations
It is essential to investigate secondary causes of hypertriglyceridemia, such as high fat diet, excessive alcohol intake, certain medications, and medical conditions (e.g., diabetes mellitus, hypothyroidism) 4. Patients should be evaluated for other components of the metabolic syndrome, including abdominal obesity, insulin resistance, low high-density lipoprotein (HDL), high triglyceride, and hypertension 4.