What is the treatment for hypertriglyceridemia?

Treatment of Hypertriglyceridemia

The treatment of hypertriglyceridemia should begin with comprehensive lifestyle modifications, followed by pharmacological therapy based on triglyceride levels, with fibrates being the first-line medication for severe hypertriglyceridemia (≥500 mg/dL). 1, 2

Classification of Triglyceride Levels

• Normal: <150 mg/dL
• Borderline high: 150-199 mg/dL
• High: 200-499 mg/dL
• Very high: ≥500 mg/dL
• Severe: 1,000-1,999 mg/dL
• Very severe: ≥2,000 mg/dL 2

Treatment Algorithm Based on Triglyceride Levels

For All Patients with Hypertriglyceridemia:

1. Lifestyle Modifications
   • Weight reduction (5-10% body weight loss can reduce triglycerides by ~20%) 1, 2
   • Physical activity (minimum 150 minutes per week of moderate-intensity or 75 minutes of vigorous aerobic activity) 1, 2
   • Dietary modifications:
     • Reduce added sugars (<6% of daily calories) 1
     • Limit refined carbohydrates 2
     • Increase soluble fiber (10-25g/day) 2
     • Reduce or eliminate alcohol consumption 1, 2
     • Smoking cessation 2

For Triglycerides 150-499 mg/dL:

1. Continue lifestyle modifications
2. Pharmacological Therapy:
   • Statins as first-line therapy if 10-year ASCVD risk ≥5% or with diabetes 2
   • Target LDL-C reduction as primary goal 2

For Triglycerides 500-999 mg/dL:

1. More aggressive lifestyle modifications:

   • Further restrict added sugars to <5% of daily calories 1
   • Limit total fat to 20-25% of daily calories 1, 2
   • Complete alcohol abstinence 1

2. Pharmacological Therapy:

   • Fibrates (fenofibrate 54-160 mg daily) as first-line therapy 2, 3
   • Consider omega-3 fatty acids (4g/day) 2
   • If LDL-C also elevated, consider statin therapy in combination with fibrate 2

For Triglycerides ≥1,000 mg/dL:

1. Most aggressive lifestyle modifications:

   • Eliminate added sugars 1
   • Restrict total fat to 10-15% of daily calories 1, 2
   • Complete alcohol abstinence 1

2. Pharmacological Therapy:

   • Fibrates (fenofibrate 54-160 mg daily) 2, 3
   • Consider hospital admission if symptomatic or showing signs of pancreatitis 2
   • Consider combination therapy with omega-3 fatty acids 2

Fenofibrate Dosing Guidelines

• Initial dose for severe hypertriglyceridemia: 54-160 mg per day 3
• Dosage should be individualized according to patient response 3
• Adjust dose following repeat lipid determinations at 4-8 week intervals 3
• Maximum dose: 160 mg once daily 3
• For patients with impaired renal function: start at 54 mg per day 3

Monitoring and Follow-up

• Check lipid panels 4-8 weeks after initiating therapy 2
• Primary goal: reduce triglycerides to <150 mg/dL 2
• For severe hypertriglyceridemia: immediate goal is to reduce triglycerides to <500 mg/dL to prevent pancreatitis 2
• Monitor liver and renal function with pharmacological therapy, especially when using fibrates 2

Important Considerations and Cautions

• Combination of statins with gemfibrozil increases risk of myositis; fenofibrate is preferred when combining with statins 2
• Evaluate for secondary causes of hypertriglyceridemia:
  • Hypothyroidism
  • Diabetes mellitus
  • Medications (estrogens, tamoxifen, retinoids, immunosuppressants, beta-blockers) 2, 3
• Markedly elevated triglycerides (>2,000 mg/dL) significantly increase risk of pancreatitis 3
• Fenofibrate should be given with meals to optimize bioavailability 3
• Consider withdrawing therapy if inadequate response after two months of maximum dose 3

By following this structured approach to managing hypertriglyceridemia, clinicians can effectively reduce triglyceride levels, minimize the risk of pancreatitis in severe cases, and potentially reduce cardiovascular risk in patients with elevated triglycerides.