What is the treatment for hypertriglyceridemia?

Treatment of Hypertriglyceridemia

Lifestyle interventions are the first line of therapy for all patients with hypertriglyceridemia, with pharmacological treatment added based on triglyceride levels and cardiovascular risk. 1

Classification and Initial Approach

Hypertriglyceridemia severity determines treatment approach:

• Mild to moderate: 150-499 mg/dL
• Severe: 500-999 mg/dL
• Very severe: ≥1,000 mg/dL

Step 1: Identify and Address Secondary Causes

• Uncontrolled diabetes
• Hypothyroidism
• Alcohol consumption
• Medications (thiazides, beta-blockers, estrogens)
• Renal disease
• Pregnancy
• High-fat/high-carbohydrate diet

Lifestyle Interventions

For All Patients with Hypertriglyceridemia:

• Weight loss: 5-10% reduction in body weight can decrease triglycerides by 20%, with potential reductions of up to 70% 1
• Physical activity: At least 150 minutes/week of moderate-intensity or 75 minutes/week of vigorous aerobic activity 1
• Dietary modifications:
  • Reduce refined carbohydrates and added sugars
  • Increase dietary fiber (>10g/day of soluble fiber)
  • Limit alcohol consumption or abstain completely

Specific Dietary Recommendations by Triglyceride Level:

• TG 150-499 mg/dL: Total fat 30-35% of calories, restrict added sugars to <6% 1
• TG 500-999 mg/dL: Total fat 20-25% of calories, restrict added sugars to <5%, abstain from alcohol 1
• TG ≥1,000 mg/dL: Total fat 10-15% of calories, eliminate added sugars, complete alcohol abstinence 1

Pharmacological Treatment

For TG ≥500 mg/dL (Severe Hypertriglyceridemia):

Pharmacotherapy is indicated to reduce the risk of acute pancreatitis 1:

1. Fibrates (first-line therapy):

   • Reduce triglycerides by 30-50%
   • FDA-approved for hypertriglyceridemia 2
   • Particularly effective for Fredrickson Types IV and V hyperlipidemia 2

2. Prescription omega-3 fatty acids:

   • Icosapent ethyl (IPE) 4g/day (2g twice daily with food)
   • REDUCE-IT trial showed 25% relative risk reduction in cardiovascular events in patients with established CVD or diabetes plus risk factors 1
   • Particularly effective for TG ≥500 mg/dL 1

3. Statins:

   • Moderate to high-intensity statins can reduce triglycerides by 10-30% 1
   • Consider as first-line when LDL-C is also elevated
   • Higher doses may be moderately effective at reducing triglyceride levels 1

For TG ≥1,000 mg/dL (Very Severe Hypertriglyceridemia):

• Immediate implementation of very low-fat diet (<10-15% of calories) 1
• Consider hospitalization for patients with abdominal pain or pancreatitis 3
• Fibrates and/or prescription omega-3 fatty acids 1
• Consider insulin/dextrose infusion for acute management in diabetic patients 3

Treatment Algorithm

1. For all patients:

   • Implement appropriate lifestyle modifications
   • Address secondary causes
   • Consider referral to registered dietitian nutritionist 1

2. For TG 150-499 mg/dL:

   • If patient has ASCVD or diabetes with additional risk factors:
     • Start moderate to high-intensity statin
     • Consider adding icosapent ethyl 4g/day if TG remains elevated despite statin therapy 1

3. For TG 500-999 mg/dL:

   • Start fibrate therapy
   • Add prescription omega-3 fatty acids if needed
   • Consider statin therapy if LDL-C is also elevated

4. For TG ≥1,000 mg/dL:

   • Immediate very low-fat diet (<10-15% of calories)
   • Start fibrate therapy
   • Add prescription omega-3 fatty acids
   • Consider hospitalization if symptomatic

Monitoring and Follow-up

• Reassess lipid levels 4-12 weeks after initiating therapy 1
• Once goals achieved, monitor every 6-12 months 1
• For patients with TG 500-999 mg/dL, aim to reduce TG to <500 mg/dL to prevent pancreatitis
• For patients with TG ≥1,000 mg/dL, more aggressive monitoring may be needed

Special Considerations

• Combination therapy: When monotherapy is insufficient, combinations of statins with fibrates or omega-3 fatty acids may be necessary 1
• Caution: Combination of statins with fibrates (especially gemfibrozil) increases risk of myositis 1
• Diabetes: Improving glycemic control can significantly reduce triglyceride levels in diabetic patients 1