What is the intervention for elevated triglycerides (hypertriglyceridemia)?

Management of Triglycerides at 300 mg/dL

For triglyceride levels of 300 mg/dL, aggressive lifestyle modifications should be implemented as first-line therapy, followed by pharmacotherapy with fibrates or omega-3 fatty acids if lifestyle changes are insufficient. 1, 2

Step 1: Lifestyle Interventions

Dietary Modifications

• Adjust fat intake based on triglyceride level:
  • For triglycerides 300 mg/dL (in the 150-499 mg/dL range), implement a moderate-fat diet (30-35% of calories) 1
  • Reduce simple and refined carbohydrates, especially added sugars (limit to <10% of calories) 2
  • Eliminate sugar-sweetened beverages 2
  • Increase soluble fiber intake (>10 g/day) 1
  • Replace refined grains with fiber-rich whole grains 2
  • Choose whole fruits over fruit juices 2
  • Include omega-3 fatty acids from fatty fish (1-2 seafood meals per week) 2

Weight Management

• Target 5-10% weight loss, which can decrease triglycerides by approximately 20% 1, 2
• Weight loss is considered the most effective lifestyle intervention for triglyceride reduction, potentially lowering levels by up to 70% in some patients 2

Physical Activity

• Engage in at least 150 minutes per week of moderate-intensity aerobic activity 2
• Regular aerobic training can decrease triglycerides by approximately 11% 2
• Resistance training can decrease triglycerides by about 6% 2

Alcohol Restriction

• Complete alcohol restriction is recommended as alcohol can significantly elevate triglyceride levels 1, 2

Step 2: Address Secondary Causes

• Evaluate and treat underlying conditions that may contribute to hypertriglyceridemia:
  • Uncontrolled diabetes (optimize glycemic control) 1
  • Hypothyroidism 2
  • Review medications that can raise triglycerides (thiazides, beta-blockers, estrogen, corticosteroids) 1, 2

Step 3: Pharmacotherapy (if triglycerides remain elevated after 4-8 weeks of lifestyle changes)

For Triglycerides 300 mg/dL (150-499 mg/dL range):

1. Assess ASCVD risk:

   • If 10-year ASCVD risk ≥7.5% or diabetes present, consider statin therapy 1, 2
   • If triglycerides remain elevated despite statin therapy, consider adding:
     • Prescription omega-3 fatty acids, particularly icosapent ethyl 4 g/day (shown to reduce cardiovascular events by 25% in the REDUCE-IT trial) 2, 3

2. If statin therapy is not indicated:

   • Consider fibrates (fenofibrate) as initial therapy 4, 5
   • Initial dose of fenofibrate is 54-160 mg per day, individualized according to patient response 4
   • Maximum dose is 160 mg once daily 4

Monitoring and Follow-up

• Monitor triglyceride levels every 4-8 weeks until stabilized, then every 3 months 2
• Target triglyceride level of <500 mg/dL to reduce pancreatitis risk 2
• Adjust therapy based on response and tolerance

Important Considerations and Pitfalls

• Combination therapy caution: Statin-fibrate combinations increase risk of myopathy and should generally be avoided 2
• Renal function: For patients with impaired renal function, start fenofibrate at lower doses (54 mg/day) 4
• Omega-3 fatty acids: May increase bleeding risk when combined with anticoagulants or antiplatelet agents; use caution in patients with fish allergies 2
• Carbohydrate restriction: Very low-carbohydrate diets (<10% of calories from carbohydrates) can provide greater triglyceride reduction (24 mg/dL) compared to moderate restriction 1
• Higher-fat vs. lower-fat diets: When pursuing weight loss, higher-fat, lower-carbohydrate diets are more effective for triglyceride reduction than lower-fat, higher-carbohydrate diets 2

The combination of multiple dietary interventions (weight loss, exercise, alcohol restriction, carbohydrate reduction, and increased unsaturated fat) provides the most potent means of lowering triglycerides 6, and should be implemented before initiating pharmacotherapy 7, 8.