What is the treatment for elevated triglycerides (hypertriglyceridemia)?

Treatment for Elevated Triglycerides (Hypertriglyceridemia)

Lifestyle modifications are the first-line treatment for all levels of hypertriglyceridemia, with medication therapy added based on triglyceride levels and cardiovascular risk. 1

Assessment and Classification

Hypertriglyceridemia is classified by severity:

• Borderline-high: 150-199 mg/dL
• High: 200-499 mg/dL
• Severe: 500-999 mg/dL
• Very severe: ≥1,000 mg/dL 1

Before initiating treatment, evaluate for:

• Secondary causes: diabetes, hypothyroidism, renal disease, alcohol use, medications (thiazides, beta-blockers, estrogen, corticosteroids) 1
• Cardiovascular risk factors: family history, obesity, hypertension, abnormal glucose metabolism 1

Treatment Algorithm Based on Triglyceride Levels

1. For All Patients with Hypertriglyceridemia (TG ≥150 mg/dL)

Lifestyle Interventions:

• Diet modifications:

  • Reduce added sugars to <6% of daily calories
  • Limit total fat to 30-35% of daily calories
  • Increase soluble fiber (>10g/day)
  • Replace sugar-sweetened beverages with no-calorie alternatives
  • Choose fresh fruit instead of pastries/desserts 1

• Physical activity:

  • At least 150 minutes/week of moderate-intensity or 75 minutes/week of vigorous aerobic activity
  • Regular endurance exercise is most effective when baseline triglycerides are elevated 1

• Weight management:

  • Target 5-10% weight loss (can reduce triglycerides by up to 20%)
  • Gradual, sustained weight loss rather than rapid weight loss 1

• Alcohol restriction:

  • Limit alcohol intake for mild-moderate hypertriglyceridemia
  • Complete abstinence for severe hypertriglyceridemia 1

2. For Triglycerides 500-999 mg/dL (Severe)

Additional dietary restrictions:

• Further restrict added sugars to <5% of daily calories
• Reduce total fat to 20-25% of daily calories
• Complete alcohol abstinence 1

Pharmacotherapy:

• Fibrates are first-line medication therapy for patients at risk of pancreatitis

  • Fenofibrate 54-160 mg daily (initial dose should be individualized based on response) 1, 2
  • Reduces triglycerides by 46-54% in clinical trials 2

• Prescription omega-3 fatty acids (4g/day)

  • Can reduce triglycerides by ≥30% 3
  • Options include EPA+DHA combinations or EPA-only formulations 1, 3

• Niacin can be considered as an alternative or adjunct therapy 1

3. For Triglycerides ≥1,000 mg/dL (Very Severe)

Extreme dietary restrictions:

• Eliminate all added sugars
• Restrict total fat to 10-15% of daily calories
• Complete alcohol abstinence 1

Aggressive pharmacotherapy:

• Immediate initiation of fibrates 1, 2
• Consider combination therapy with prescription omega-3 fatty acids 1, 3
• For patients with acute pancreatitis risk, consider insulin infusion and plasmapheresis if triglycerides remain ≥1,000 mg/dL despite treatment 4

4. For Patients with Cardiovascular Disease Risk

• Statin therapy should be considered for patients with:

  • Established cardiovascular disease
  • Diabetes
  • 10-year ASCVD risk ≥5% 1
  • Statins provide 10-30% triglyceride reduction 1

• For high-risk patients with persistent hypertriglyceridemia despite statin therapy:

  • Consider adding high-dose icosapent ethyl (purified EPA) 4, 3
  • In the REDUCE-IT trial, this reduced cardiovascular events by 25% 3

Important Clinical Considerations

• Treatment goals:

  • For moderate hypertriglyceridemia: target non-HDL cholesterol level 30 mg/dL higher than LDL goal 1
  • For severe hypertriglyceridemia: reduce triglycerides to <500 mg/dL to prevent pancreatitis 1, 5

• Medication pitfalls:

  • Statins alone are insufficient for severe hypertriglyceridemia 1
  • Fenofibrate may increase LDL-C levels in some patients 2
  • Monitor renal function when using fibrates, especially in elderly patients 2

• Monitoring:

  • Assess response after 4-12 weeks of lifestyle intervention 1
  • For pharmacotherapy, evaluate lipid levels 4-8 weeks after initiation or dose adjustment 2
  • Consider discontinuing medication if inadequate response after 2 months at maximum dose 2

The management of hypertriglyceridemia requires a structured approach based on triglyceride levels and cardiovascular risk. While lifestyle modifications form the foundation of treatment for all patients, medication therapy should be added promptly for those with severe hypertriglyceridemia to reduce the risk of pancreatitis and cardiovascular events.