How to lower hypertriglyceridemia?

Management of Hypertriglyceridemia

The most effective approach to lower triglycerides is implementing aggressive lifestyle modifications including dietary changes, weight loss, physical activity, and alcohol restriction, which can reduce triglyceride levels by up to 70%. 1, 2

Lifestyle Interventions (First-Line Treatment)

Dietary Modifications

• Carbohydrate Restriction:

  • Reduce carbohydrate intake, especially refined carbohydrates and added sugars 1
  • Very low-carbohydrate diets (3-30% of energy) can decrease triglycerides by 23.9 mg/dL 1
  • Low-carbohydrate diets (30-40% of energy) can decrease triglycerides by 15.9 mg/dL 1
  • Limit added sugars to <10% of calories for TG <500 mg/dL and <5% of calories for TG ≥500 mg/dL 1

• Fat Intake:

  • Adjust total fat content according to baseline triglyceride levels 1
  • Include omega-3 fatty acids from fatty fish (salmon, rainbow trout, tuna) 1
  • Consume 1-2 seafood meals per week 1

• Specific Dietary Recommendations:

  • Replace refined grains with fiber-rich whole grains 1
  • Choose whole fruits over fruit juices 1
  • Avoid sugar-sweetened beverages 1, 2
  • For severe hypertriglyceridemia (≥500 mg/dL), limit total fat to 20-25% of daily calories 2

Weight Loss

• Target 5-10% reduction in body weight, which can decrease triglycerides by 20% 1
• Weight loss is considered the most effective lifestyle intervention for lowering triglycerides 1
• Some patients may experience up to 70% reduction in triglycerides with weight loss 1, 2

Physical Activity

• Engage in at least 150 minutes per week of moderate-intensity aerobic activity 1, 2
• Regular aerobic training can decrease triglycerides by about 11% 1
• Resistance training decreases triglycerides by about 6% 1
• The effect is greatest when baseline triglyceride levels are elevated (≥150 mg/dL) 1

Alcohol Restriction

• Complete alcohol restriction is recommended for patients with hypertriglyceridemia 2
• Alcohol can significantly elevate triglyceride levels, especially in those with genetic predisposition 1

Pharmacological Interventions (When Lifestyle Changes Are Insufficient)

For Severe Hypertriglyceridemia (≥500 mg/dL)

• Fibrates:
  • Initial dose of fenofibrate 54-160 mg per day 3, 4
  • Dosage should be adjusted based on response at 4-8 week intervals 3, 4
  • Maximum dose is 145-160 mg once daily 3, 4
  • Use with caution in patients with renal impairment 3, 4

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

• Statins:

  • First-line pharmacotherapy for patients with ASCVD risk ≥7.5% 2
  • Moderate to high-intensity statin therapy recommended 2

• Prescription Omega-3 Fatty Acids:

  • Consider icosapent ethyl 4g/day for patients on statins with controlled LDL but persistent elevated triglycerides 2
  • Demonstrated 25% relative risk reduction in cardiovascular events 2
  • Use with caution in patients on anticoagulants or with fish allergies 2

Monitoring and Follow-Up

• Monitor triglyceride levels every 4-8 weeks until stabilized, then every 3 months 2
• Target triglyceride level <500 mg/dL to reduce pancreatitis risk 2
• Consider more aggressive intervention if triglycerides exceed 1000 mg/dL 2

Addressing Secondary Causes

• Evaluate and treat:
  • Uncontrolled diabetes 1, 2
  • Hypothyroidism 1, 2
  • Review medications that can raise triglycerides (thiazides, beta-blockers, estrogen, corticosteroids) 1, 2, 3

Clinical Pearls and Pitfalls

• Higher-fat, lower-carbohydrate diets are more effective for triglyceride reduction than lower-fat, higher-carbohydrate diets when pursuing weight loss 1
• The risk of acute pancreatitis increases significantly when triglyceride levels exceed 500 mg/dL 2
• Statin-fibrate combinations increase the risk of myopathy and should generally be avoided 2
• Patients should be placed on appropriate lipid-lowering diet before starting medications 3, 4
• Therapy should be withdrawn if no adequate response after two months of maximum recommended dose 3, 4

By implementing these comprehensive lifestyle changes and appropriate pharmacotherapy when needed, most patients can achieve significant reductions in triglyceride levels, reducing their risk of pancreatitis and cardiovascular disease.