How are high triglycerides managed?

Management of High Triglycerides

The management of high triglycerides should begin with aggressive lifestyle modifications, followed by pharmacological therapy based on triglyceride levels and cardiovascular risk, with statins as first-line medication for moderate hypertriglyceridemia and fibrates or prescription omega-3 fatty acids added for severe hypertriglyceridemia. 1

Classification of Hypertriglyceridemia

Triglyceride levels are classified as:

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

Causes of High Triglycerides

Hypertriglyceridemia is often multifactorial. Common causes include:

1. Lifestyle factors:

   • Obesity and metabolic syndrome
   • Physical inactivity
   • High carbohydrate diet (especially refined carbohydrates)
   • Excessive alcohol consumption
   • Smoking

2. Medical conditions:

   • Diabetes mellitus
   • Hypothyroidism
   • Chronic liver disease
   • Chronic kidney disease and nephrotic syndrome

3. Medications that increase triglycerides 2

4. Genetic factors 3

Management Algorithm

Step 1: Lifestyle Modifications (First-line for all patients)

• Weight loss: 5-10% reduction in body weight can decrease triglycerides by up to 20% 1, 4

  • More aggressive weight loss can reduce triglycerides by 50-70% 2

• Dietary modifications:

  • Reduce refined carbohydrates and added sugars
  • Limit saturated fat to <7% of total calories
  • Increase consumption of omega-3 rich foods (fatty fish 2+ servings/week)
  • Increase dietary fiber (>10g/day)
  • For severe hypertriglyceridemia (≥500 mg/dL): implement a very low-fat diet 2

• Physical activity:

  • 150 minutes/week moderate-intensity or 75 minutes/week vigorous-intensity exercise
  • Regular aerobic training can decrease triglycerides by approximately 11% 1

• Alcohol reduction or elimination, especially important in those with triglycerides ≥500 mg/dL 2

Step 2: Pharmacological Therapy Based on Triglyceride Levels

For Moderate Hypertriglyceridemia (150-499 mg/dL):

1. Statins are first-line therapy for patients with:

   • Established ASCVD
   • Diabetes mellitus
   • 10-year ASCVD risk ≥7.5% 2, 1

2. Consider triglyceride level as a risk-enhancing factor when deciding on statin intensity 2

For Severe Hypertriglyceridemia (≥500 mg/dL):

1. Primary goal: Reduce triglycerides to <500 mg/dL to prevent pancreatitis 1

2. Pharmacological options:

   • Fibrates (e.g., fenofibrate 54-160 mg daily) 2, 1
   • Prescription omega-3 fatty acids:
     • Icosapent ethyl 4g/day (2g twice daily with food) 5
     • Other prescription omega-3 preparations containing EPA+DHA 2

3. Combination therapy may be necessary:

   • For patients with elevated LDL-C and high cardiovascular risk, consider statin plus fibrate or omega-3 fatty acids 1, 6
   • Monitor for increased risk of myositis with statin-fibrate combinations 1

Monitoring and Follow-up

• Reassess lipid profile after 4-12 weeks of lifestyle interventions 1
• If pharmacotherapy is initiated, monitor lipid levels every 4-8 weeks initially 1
• Once goals are achieved, follow-up every 6-12 months 1
• Screen annually for diabetes if metabolic syndrome is present 1

Special Considerations

• Bleeding risk: Omega-3 fatty acids may increase bleeding risk, especially when combined with anticoagulants or antiplatelet agents 5
• Atrial fibrillation: Icosapent ethyl has been associated with increased risk of atrial fibrillation requiring hospitalization, particularly in patients with previous history of atrial fibrillation 5
• Fish allergy: Use caution with omega-3 fatty acids in patients with known fish or shellfish allergies 5

Treatment Goals

1. For triglycerides ≥500 mg/dL: Reduce to <500 mg/dL to prevent pancreatitis
2. Secondary goal: Reduce triglycerides to <150 mg/dL 1
3. For patients with ASCVD risk: LDL-C reduction remains a primary goal regardless of triglyceride levels 1

By following this structured approach to managing hypertriglyceridemia, clinicians can effectively reduce the risk of pancreatitis in patients with severe hypertriglyceridemia and potentially reduce cardiovascular risk in those with moderate hypertriglyceridemia.