What is recommended to lower triglycerides?

Recommendations for Lowering Triglycerides

The most effective approach to lower triglycerides is to first address lifestyle factors (diet, weight, physical activity) as primary intervention, followed by pharmacological therapy with fibrates, omega-3 fatty acids, or niacin when lifestyle changes are insufficient, particularly for triglyceride levels above 500 mg/dL. 1

Classification and Treatment Approach

Moderate Hypertriglyceridemia (175-499 mg/dL)

1. First-line: Lifestyle Modifications

   • Reduce saturated fat to <7% of total calories 1
   • Limit dietary cholesterol to <200 mg/day 1
   • Reduce trans fat to <1% of energy 1
   • Increase viscous (soluble) fiber (10-25 g/day) 1
   • Add plant stanols/sterols (2 g/day) 1
   • Promote daily physical activity 1
   • Implement weight management for overweight/obese patients 1
   • Reduce refined carbohydrates and alcohol consumption 1

2. Address Secondary Causes

   • Optimize glycemic control in diabetes 1
   • Treat underlying conditions (hypothyroidism, kidney disease, liver disease) 1
   • Review medications that may increase triglycerides 1

3. Pharmacological Options (if lifestyle changes insufficient)

   • Consider statin therapy if ASCVD risk ≥7.5% 1
   • Fibrates (fenofibrate, gemfibrozil) 1, 2
   • Omega-3 fatty acids (2-4 g/day) 1
   • Niacin 1, 3

Severe Hypertriglyceridemia (≥500 mg/dL)

1. Urgent Intervention Required (to prevent pancreatitis)
   • Very low-fat diet (<15% of total calories) 1, 4
   • Complete alcohol restriction 1
   • Fibrate therapy 1, 2
   • High-dose omega-3 fatty acids (2-4 g/day) 1
   • Niacin 1
   • Optimize glycemic control (insulin therapy may be needed) 1

Efficacy of Interventions

Lifestyle Modifications

• Diet and weight loss: Can reduce triglycerides by 20-30% 5
• Regular physical activity: Reduces triglycerides and improves insulin sensitivity 1
• Replacing saturated fat with unsaturated fat: More effective than replacing with carbohydrates 4

Pharmacological Agents

• Fibrates: Most potent, can reduce triglycerides by up to 50% 1, 2
• Omega-3 fatty acids: Can reduce triglycerides by up to 40% 1
• Niacin: Can reduce triglycerides by 30-70% 1, 3
• Statins: Modest triglyceride reduction, but important for overall cardiovascular risk 1

Important Considerations and Pitfalls

1. Drug Interaction Concerns

   • Combination of high-dose statin plus fibrate increases risk of myopathy; keep statin doses relatively low with this combination 1
   • Gemfibrozil has higher risk of interactions than fenofibrate when combined with statins 1
   • Bile acid sequestrants are relatively contraindicated when triglycerides are >200 mg/dL 1

2. Special Populations

   • Patients with diabetes: Optimize glycemic control first, as this can significantly reduce triglycerides 1
   • Patients with very high triglycerides (>1000 mg/dL): Require more aggressive therapy to prevent pancreatitis 1

3. Common Pitfalls

   • Focusing only on medication without addressing lifestyle factors 5
   • Using dietary supplement niacin instead of prescription niacin 1
   • Overlooking secondary causes of hypertriglyceridemia 1
   • Failing to recognize that poor dietary choices can overwhelm medication effects 5

Treatment Algorithm

1. Assess triglyceride level and cardiovascular risk
2. For all patients: Implement lifestyle modifications
3. If triglycerides 175-499 mg/dL:
   • Continue lifestyle changes for 3-6 months
   • If inadequate response and ASCVD risk ≥7.5%, consider statin therapy
   • If triglycerides remain elevated, add fibrate, omega-3 fatty acids, or niacin
4. If triglycerides ≥500 mg/dL:
   • Immediate lifestyle intervention (very low-fat diet, no alcohol)
   • Start fibrate, omega-3 fatty acids, or niacin
   • Optimize glycemic control if diabetic
   • Monitor closely to prevent pancreatitis

By following this structured approach, most patients can achieve significant reductions in triglyceride levels and associated cardiovascular risk.