What is the treatment for hypertriglyceridemia?

Treatment for Hypertriglyceridemia

Fibrates are the first-line pharmacological treatment for severe hypertriglyceridemia (≥500 mg/dL), with fenofibrate being the preferred agent at an initial dose of 54-160 mg per day. 1

Classification of Hypertriglyceridemia

Hypertriglyceridemia is classified based on fasting serum triglyceride levels:

• 150-199 mg/dL: Mild
• 200-499 mg/dL: Moderate
• 500-999 mg/dL: Severe
• ≥1000 mg/dL: Very severe 2, 1

Treatment Approach Based on Severity

1. Lifestyle Modifications (All Patients)

• Dietary Changes:

  • Limit added sugars to <5% of calories for triglycerides ≥500 mg/dL 1
  • Implement extreme dietary fat restriction (<5% of total calories) until triglycerides are <1000 mg/dL 1
  • Consume fatty fish (salmon, trout) for omega-3 fatty acids 1
  • Replace refined grains with fiber-rich whole grains 1
  • Choose whole fruits over fruit juices 1
  • Avoid sugar-sweetened beverages 1

• Physical Activity:

  • At least 150 minutes per week of moderate-intensity aerobic activity (decreases triglycerides by ~11%) 1
  • Include resistance training (decreases triglycerides by ~6%) 1

• Other Lifestyle Measures:

  • Weight loss if overweight/obese 1
  • Complete alcohol abstinence, especially for high-risk individuals 1
  • Smoking cessation 1

2. Address Secondary Causes

• Evaluate and treat underlying conditions:

  • Uncontrolled diabetes
  • Hypothyroidism
  • Renal or liver disease
  • Pregnancy
  • Autoimmune disorders 2

• Review medications that may elevate triglycerides:

  • Thiazides
  • Beta-blockers
  • Estrogen
  • Isotretinoin
  • Corticosteroids
  • Antiretroviral protease inhibitors
  • Antipsychotics 2

3. Pharmacological Treatment

For Severe to Very Severe Hypertriglyceridemia (≥500 mg/dL)

• First-line: Fibrates (fenofibrate 54-160 mg daily) 1, 3

  • Reduces risk of pancreatitis
  • Maximum dose: 160 mg once daily 3
  • For renal impairment: Start at 54 mg/day 3

• Acute Management (for very severe cases >2000 mg/dL):

  • Consider plasmapheresis for rapid triglyceride reduction 1
  • Intravenous insulin (with or without heparin) if hyperglycemia is present 1

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

• Treatment options:
  • Prescription omega-3 fatty acids (4 g/day) 1
  • Statins if elevated LDL-C or increased cardiovascular risk 1
  • Niacin as an alternative option 4

Combination Therapy

• Fibrates + omega-3 fatty acids for resistant cases 1
• Caution with statin + fibrate combinations due to increased risk of myositis 1
• Specifically avoid gemfibrozil + statins (higher risk than fenofibrate + statins) 1

Monitoring

• Check triglyceride levels every 4-8 weeks until stabilized, then every 3 months 1
• Target triglyceride level: <500 mg/dL to reduce pancreatitis risk 1
• More aggressive intervention needed if triglycerides exceed 1000 mg/dL 1

Special Considerations

• Pregnancy: Conduct pregnancy tests before starting treatment 1
• Bleeding risk: Omega-3 fatty acids may increase bleeding risk when combined with anticoagulants 1
• Fish allergies: Use caution with omega-3 supplements in patients with fish allergies 1
• Adolescents: Pharmacotherapy generally not first-line for mild-to-moderate hypertriglyceridemia 1

Treatment Algorithm

1. Implement aggressive lifestyle modifications for all patients
2. Identify and address secondary causes
3. For TG ≥500 mg/dL: Start fibrate therapy (fenofibrate 54-160 mg daily)
4. For TG 200-499 mg/dL with cardiovascular risk: Consider statins ± omega-3 fatty acids
5. For resistant cases: Consider combination therapy
6. For acute severe cases (>2000 mg/dL): Consider plasmapheresis or insulin therapy

The goal of treatment is to reduce the risk of pancreatitis in patients with severe hypertriglyceridemia (≥500 mg/dL) and cardiovascular disease risk in those with moderate hypertriglyceridemia (200-499 mg/dL) 1, 5.