What is the treatment for hypertriglyceridemia?

Treatment of Hypertriglyceridemia

The treatment of hypertriglyceridemia should begin with aggressive lifestyle modifications, followed by fibrate therapy for severe cases (≥500 mg/dL) to prevent pancreatitis, while statins are preferred when cardiovascular risk is elevated. 1

Classification of Hypertriglyceridemia

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

First-Line Treatment: Lifestyle Modifications

Dietary Changes

• Implement a very low-fat diet (20-25% of daily calories)
• Restrict added sugars to <5% of daily calories
• Avoid refined carbohydrates
• Consider omega-3 fatty acids from dietary sources 1

Other Essential Lifestyle Modifications

• Complete alcohol restriction (crucial for patients with hypertriglyceridemia)
• Regular aerobic exercise (150 minutes/week of moderate intensity)
• Weight loss for overweight/obese patients
• Smoking cessation 1

Secondary Causes to Evaluate and Address

• Uncontrolled diabetes mellitus
• Hypothyroidism
• Medications that raise triglycerides:
  • Thiazide diuretics
  • Beta-blockers
  • Estrogen
  • Isotretinoin
  • Corticosteroids
  • Antiretrovirals
  • Antipsychotics 1, 2
• Renal or liver disease
• Family history of dyslipidemia 1

Pharmacological Treatment

For Severe Hypertriglyceridemia (≥500 mg/dL)

• First-line medication: Fibrates (e.g., fenofibrate) to prevent acute pancreatitis
  • Initial dose: 54-160 mg daily with meals
  • Maximum dose: 160 mg once daily
  • Adjust dose based on renal function (54 mg/day for mild-moderate renal impairment)
  • Contraindicated in severe renal impairment, active liver disease, and preexisting gallbladder disease 1, 2
• Second-line option: Prescription omega-3 fatty acids (4g/day) if triglycerides remain elevated despite fibrate therapy 1

For Mild to Moderate Hypertriglyceridemia (150-499 mg/dL)

• If ASCVD risk ≥7.5%: Consider statin therapy to address cardiovascular risk 1
• If low HDL and elevated triglycerides: Consider extended-release niacin 3

Monitoring and Follow-up

• Monitor triglyceride levels every 4-8 weeks until stabilized
• Once stabilized, check every 3 months
• Target triglyceride level: <500 mg/dL to reduce pancreatitis risk 1
• Consider discontinuing therapy if no adequate response after two months on maximum dose 2

Special Considerations

Combination Therapy

• Caution: Combination of statins and fibrates increases risk of myopathy and should generally be avoided 1

Renal Impairment

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

Elderly Patients

• Dose selection should be based on renal function 2

Medication-Induced Hypertriglyceridemia

• For isotretinoin-induced hypertriglyceridemia: Monitor triglycerides every 2-4 weeks and implement dietary modifications
• Consider discontinuation of the triggering medication when possible 1

Treatment Algorithm Based on Triglyceride Levels

1. For all patients: Implement aggressive lifestyle modifications
2. TG 150-499 mg/dL:
   • Focus on lifestyle modifications
   • If ASCVD risk ≥7.5%, add statin therapy
3. TG ≥500 mg/dL:
   • Start fibrate therapy (fenofibrate 54-160 mg/day)
   • Continue aggressive lifestyle modifications
4. TG ≥1000 mg/dL:
   • More aggressive intervention needed
   • Consider referral to lipid specialist
   • Consider combination therapy if single agent ineffective 1, 4

By following this structured approach to treating hypertriglyceridemia, clinicians can effectively reduce the risk of pancreatitis in severe cases and address cardiovascular risk in patients with mild to moderate elevations.