What is the treatment for hypertriglyceridemia?

Treatment of Hypertriglyceridemia

For hypertriglyceridemia management, a comprehensive approach combining lifestyle modifications and pharmacotherapy is recommended, with fibrates (particularly fenofibrate) as first-line medication for severe hypertriglyceridemia (≥500 mg/dL). 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

Treatment Algorithm Based on Severity

Step 1: Lifestyle Modifications (All Patients)

• Diet Modifications:

  • Very-low-fat diet (10-15% of calories from fat) 1
  • For TG ≥500 mg/dL: Limit added sugars to <5% of calories 1
  • For TG ≥1000 mg/dL: Extreme dietary fat restriction (<5% of total calories) until TG <1000 mg/dL 1
  • Consume 1-2 seafood meals weekly 1
  • Replace refined grains with fiber-rich whole grains 1
  • Choose whole fruits over fruit juices 1
  • Avoid sugar-sweetened beverages 1
  • Consider carbohydrate restriction (very low-carbohydrate diets <10% of calories) 1

• Physical Activity:

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

• Weight Management:

  • Target 5-10% weight loss in overweight/obese individuals (can lower TG by ~20%) 1

• Other Lifestyle Changes:

  • Complete alcohol abstinence (mandatory for high-risk individuals) 1
  • Smoking cessation 1

Step 2: Treat Underlying Conditions

• Optimize glycemic control in diabetes 1
• Evaluate and treat hypothyroidism, renal or liver disease, autoimmune disorders 1
• Review medications that may elevate triglycerides (thiazides, beta-blockers, estrogen, isotretinoin, corticosteroids, antiretrovirals, antipsychotics) 1

Step 3: Pharmacotherapy Based on TG Levels

For Severe Hypertriglyceridemia (≥500 mg/dL):

• First-line: Fibrates (preferably fenofibrate)
  • Initial dose: 54-160 mg daily
  • Maximum dose: 160 mg once daily 1, 2
  • Target: Reduce TG to <500 mg/dL to minimize pancreatitis risk 1

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

• With elevated LDL-C: High-dose statin as first-line 1
• With combined hyperlipidemia: Improved glycemic control plus high-dose statin 1
• If inadequate response: Consider statin plus fenofibrate 1
• For patients with controlled LDL but elevated TG: Prescription omega-3 fatty acids (4 g/day) 1

Step 4: For Very Severe Hypertriglyceridemia (≥1000 mg/dL):

• More aggressive intervention required 1
• Consider plasmapheresis for rapid TG reduction, especially when >2000 mg/dL 1
• Intravenous insulin (with or without heparin) with careful monitoring, especially with hyperglycemia 1

Monitoring and Follow-up

• Monitor TG levels every 4-8 weeks until stabilized, then every 3 months 1
• Target TG level: <500 mg/dL to reduce pancreatitis risk 1

Special Considerations and Cautions

• Combination of statins with fibrates carries increased risk of myositis; monitor carefully 1
• Avoid combination of statins with gemfibrozil (higher myositis risk than fenofibrate) 1
• Omega-3 fatty acids may increase bleeding risk with anticoagulants or antiplatelet agents 1
• Use caution with omega-3 fatty acids in patients with fish or shellfish allergies 1
• For patients with renal impairment: Start fenofibrate at 54 mg/day and adjust based on response 2
• Avoid fenofibrate in severe renal impairment 2
• Fenofibrate is contraindicated in active liver disease, preexisting gallbladder disease, and nursing mothers 2

By following this structured approach to hypertriglyceridemia management, clinicians can effectively reduce triglyceride levels and minimize associated risks of pancreatitis and cardiovascular disease.