How to manage hypertriglyceridemia due to Diane 35 (cyproterone acetate and ethinyl estradiol) use?

From the Guidelines

Managing hypertriglyceridemia due to Diane 35 requires a multifaceted approach, prioritizing lifestyle modifications and consideration of alternative contraceptives, as the current triglyceride level of 225 mg/dl is below the threshold for severe hypertriglyceridemia. According to the most recent guidelines 1, individuals with fasting triglyceride levels ≥500 mg/dL warrant evaluation for secondary causes and consideration of medical therapy to reduce the risk of pancreatitis. Since the patient's triglyceride level is 225 mg/dl, which is below this threshold, the focus should be on addressing lifestyle factors, secondary factors, and medications that raise triglycerides.

Lifestyle Modifications

• Adopt a low-fat diet (less than 20% of calories from fat)
• Engage in regular exercise (30 minutes daily)
• Manage weight
• Avoid alcohol and refined carbohydrates
• Consider omega-3 fatty acid supplements (2-4g daily) to help reduce triglyceride levels 1.

Medical Considerations

• Consider discontinuing Diane 35 and switching to a progestin-only contraceptive or non-hormonal method in consultation with a healthcare provider, as Diane 35 can increase triglycerides due to its components 1.
• For patients with elevated triglycerides (150–499 mg/dL) and cardiovascular risk factors on a statin with managed LDL cholesterol, the addition of icosapent ethyl can be considered to reduce cardiovascular risk 1.

Monitoring

Regular monitoring of lipid levels every 3-6 months is essential to assess the effectiveness of the chosen management strategy and to adjust it as necessary. Baseline lipid screening before starting Diane 35 is recommended, especially for patients with pre-existing lipid disorders, obesity, diabetes, or a family history of dyslipidemia 1.

From the FDA Drug Label

The use of drugs should be considered only when reasonable attempts have been made to obtain satisfactory results with non-drug methods. If the decision is made to use drugs, the patient should be instructed that this does not reduce the importance of adhering to diet. Medications known to exacerbate hypertriglyceridemia (beta-blockers, thiazides, estrogens) should be discontinued or changed if possible prior to consideration of triglyceride-lowering drug therapy.

To manage hypertriglyceridemia due to Diane 35 (cyproterone acetate and ethinyl estradiol) use, the following steps can be taken:

• Discontinue or change the medication that is exacerbating hypertriglyceridemia, in this case, Diane 35, if possible.
• Implement non-drug methods such as dietary changes, exercise, and weight loss in obese patients.
• Control any medical problems that are contributing to the lipid abnormalities, such as diabetes mellitus and hypothyroidism.
• If the above measures are not effective, consider triglyceride-lowering drug therapy, such as fenofibrate, after reasonable attempts have been made to obtain satisfactory results with non-drug methods 2.

From the Research

Management of Hypertriglyceridemia

To manage hypertriglyceridemia due to Diane 35 (cyproterone acetate and ethinyl estradiol) use, with a triglyceride level of 225 mg/dl, consider the following:

• Dietary changes to lower cardiovascular risk, such as reducing carbohydrate intake (especially refined carbohydrates) and increasing fat (especially omega-3 fatty acids) and protein intake 3
• Moderate- to high-intensity physical activity to lower triglyceride levels and improve body composition and exercise capacity 3
• Calculating the patient's 10-year risk of atherosclerotic cardiovascular disease to determine the role of medications 3

Treatment Options

Treatment options for hypertriglyceridemia include:

• Statins, which can be considered for patients with high triglyceride levels who have borderline or intermediate risk 3, 4
• Fibrates, omega-3 fatty acids, or niacin, which can be considered for patients with severely elevated triglyceride levels to reduce the risk of pancreatitis 3, 4
• High-dose icosapent (purified eicosapentaenoic acid) can reduce cardiovascular mortality in patients at high risk who continue to have high triglyceride levels despite statin use 3
• Omega-3 fatty acids, which may be a well-tolerated and effective alternative to fibrates and niacin, and can reduce triglyceride levels by ≥30% 5

Specific Considerations

Specific considerations for managing hypertriglyceridemia due to Diane 35 use include:

• Evaluating for secondary contributors, such as diabetes mellitus, and making lifestyle adjustments aimed at weight loss and decreasing alcohol consumption 6
• Using statin and nonstatin therapies, such as omega-3 fatty acids, as needed to manage triglyceride levels and reduce cardiovascular risk 6, 5
• Monitoring triglyceride levels and adjusting treatment as needed to achieve optimal control and reduce the risk of cardiovascular disease 7