What is the treatment for hypertriglyceridemia?

Treatment for Hypertriglyceridemia

The treatment of hypertriglyceridemia should begin with comprehensive lifestyle modifications, followed by pharmacotherapy with fibrates as first-line medication for severe hypertriglyceridemia (≥500 mg/dL) and statins for moderate hypertriglyceridemia with elevated cardiovascular risk. 1

Classification and Initial Assessment

Hypertriglyceridemia is classified based on severity:

• Normal: <150 mg/dL
• Mild to moderate: 150-499 mg/dL
• Severe: 500-999 mg/dL
• Very severe: ≥1000 mg/dL 1

Before initiating treatment, evaluate for secondary causes:

• Uncontrolled diabetes
• Hypothyroidism
• Renal or liver disease
• Excessive alcohol intake
• Medications (estrogen therapy, thiazide diuretics, beta-blockers) 1, 2

Treatment Algorithm

1. Lifestyle Modifications (First-line for all patients)

For triglycerides <500 mg/dL:

• Restrict added sugars to <6% of total daily calories
• Limit total fat to 30-35% of total daily calories
• Restrict alcohol consumption
• Engage in at least 150 minutes/week of moderate-intensity aerobic activity
• Target 5-10% weight loss if overweight/obese 1

For triglycerides 500-999 mg/dL:

• Further restrict added sugars to <5% of total daily calories
• Limit total fat to 20-25% of total daily calories
• Complete alcohol abstinence
• Maintain same physical activity and weight loss goals 1

For triglycerides ≥1000 mg/dL:

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

2. Pharmacological Treatment

For Severe Hypertriglyceridemia (≥500 mg/dL):

• First-line: Fibrates (gemfibrozil, fenofibrate) to reduce pancreatitis risk 3, 1
  • Initial dose of fenofibrate: 54-160 mg daily with meals
  • Dosage should be individualized according to patient response 2

For Moderate Hypertriglyceridemia (150-499 mg/dL) with elevated ASCVD risk:

• First-line: Statins (reduce triglycerides by 10-15%) 1
• Second-line: Consider adding icosapent ethyl (purified EPA) for patients with high ASCVD risk and persistent hypertriglyceridemia despite statin therapy 1

For Patients with Diabetes:

• Glycemic control should be the first priority 3, 1
• After glycemic control is achieved, reassess triglyceride levels 1
• Then follow the algorithm above based on triglyceride levels

For Combined Hyperlipidemia:

1. Improved glycemic control plus high-dose statin
2. If inadequate response: Add fibrate (gemfibrozil, fenofibrate) 3
   • Caution: The combination of statins with fibrates may increase risk of myositis 3

Special Considerations

For Very Severe Hypertriglyceridemia (≥1000 mg/dL) with Pancreatitis:

• Hospitalization
• Extreme dietary fat restriction (<10% of calories)
• Consider insulin/dextrose infusion or therapeutic apheresis in emergency situations 1

For Patients with Renal Impairment:

• Start fenofibrate at 54 mg/day in patients with mild to moderate renal impairment
• Avoid fenofibrate in patients with severe renal impairment 2

Monitoring and Follow-up

• Monitor lipid levels periodically (every 4-8 weeks initially)
• Adjust medication dosage based on response
• Consider withdrawing therapy if no adequate response after two months of maximum dose 2
• Monitor for side effects, particularly myositis with statin-fibrate combinations 3

Common Pitfalls to Avoid

• Overlooking secondary causes of hypertriglyceridemia
• Relying solely on medications without addressing lifestyle factors
• Using statins alone for severe hypertriglyceridemia
• Inadequate dietary counseling
• Failing to address alcohol consumption 1
• Not monitoring for myositis when combining statins with fibrates 3

By following this structured approach to hypertriglyceridemia management, focusing first on lifestyle modifications and then adding appropriate pharmacotherapy based on triglyceride levels and cardiovascular risk, patients can achieve significant reductions in triglyceride levels and associated health risks.