How is elevated Very Low Density Lipoprotein (VLDL) managed?

From the Guidelines

Elevated Very Low Density Lipoprotein (VLDL) should be managed through nonpharmacological means where possible, including identification and treatment of underlying causes of elevated triglycerides, as well as lifestyle modifications. In patients with moderate hypertriglyceridemia, it is reasonable to reduce both atherogenic VLDL and associated risk factors by nonpharmacological means, such as dietary changes and increased physical activity 1. Key lifestyle modifications include:

• Reducing saturated fat, trans fat, and simple carbohydrate intake
• Increasing consumption of fruits, vegetables, and whole grains
• Weight loss of 5-10% of body weight
• Regular aerobic exercise of at least 150 minutes per week
• Limiting alcohol consumption If lifestyle changes are insufficient, medication therapy may be initiated, with statins being a reasonable choice for reducing VLDL levels, especially in patients with multiple ASCVD risk factors 1. Some key points to consider when managing elevated VLDL include:
• Identifying and treating underlying causes of elevated triglycerides, such as secondary disorders and triglyceride-raising drugs
• Monitoring for muscle toxicity when combining statins with fibrates
• Regular lipid panel monitoring every 3-6 months to assess treatment effectiveness
• Considering the use of omega-3 fatty acids, particularly for hypertriglyceridemia It is essential to note that VLDL management is crucial because these particles carry triglycerides and contribute to atherosclerosis when elevated, increasing cardiovascular disease risk 1.

From the FDA Drug Label

In patients with hypertriglyceridemia and normal cholesterolemia with or without hyperchylomicronemia, treatment with fenofibrate at dosages equivalent to fenofibrate 160 mg per day decreased primarily very low density lipoprotein (VLDL) triglycerides and VLDL cholesterol. Gemfibrozil Tablets, USP are indicated as adjunctive therapy to diet for: 1. Treatment of adult patients with very high elevations of serum triglyceride levels (Types IV and V hyperlipidemia) who present a risk of pancreatitis and who do not respond adequately to a determined dietary effort to control them

Elevated VLDL Management:

• Fenofibrate decreases VLDL triglycerides and VLDL cholesterol in patients with hypertriglyceridemia.
• Gemfibrozil is indicated for treatment of adult patients with very high elevations of serum triglyceride levels (Types IV and V hyperlipidemia) who present a risk of pancreatitis.
• The initial treatment for dyslipidemia is dietary therapy specific for the type of lipoprotein abnormality.
• Excess body weight and excess alcohol intake may be important factors in hypertriglyceridemia and should be managed prior to any drug therapy.
• Physical exercise can be an important ancillary measure, and has been associated with rises in HDL-cholesterol.
• Diseases contributory to hyperlipidemia such as hypothyroidism or diabetes mellitus should be looked for and adequately treated 2 3.

From the Research

Management of Elevated VLDL

Elevated Very Low Density Lipoprotein (VLDL) is a significant risk factor for cardiovascular disease. Managing elevated VLDL levels is crucial to reduce the risk of cardiovascular events.

• The primary approach to managing elevated VLDL levels involves lifestyle modifications, including dietary changes and increased physical activity.
• Pharmacological interventions, such as prescription omega-3 fatty acids, fibrates, and niacin, may be necessary for patients with severe hypertriglyceridemia [ 4, 5,6 ].
• Prescription omega-3 fatty acids, containing eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), have been shown to reduce triglyceride levels by 45% and VLDL cholesterol levels by more than 50% in patients with triglyceride levels above 500 mg/dl [ 4 ].
• Fibrates, such as gemfibrozil and fenofibrate, have been shown to reduce plasma triglyceride levels while raising high-density lipoprotein (HDL) cholesterol levels 5, 7.
• The combination of a statin and a fibrate may be used to manage patients with atherogenic lipid profiles, but it raises the risk of myopathy and rhabdomyolysis 7.
• Baseline VLDL cholesterol levels have been associated with the magnitude of triglyceride lowering on statins, fenofibric acid, or their combination in patients with mixed dyslipidemia 8.

Treatment Options

Treatment options for elevated VLDL levels include:

• Prescription omega-3 fatty acids [ 4 ]
• Fibrates, such as gemfibrozil and fenofibrate 5, 7
• Niacin 6
• Statins 6, 7, 8
• Combination therapy with a statin and a fibrate 7