How are high triglycerides managed?

Management of High Triglycerides

Lifestyle modifications are the foundation of hypertriglyceridemia management, with pharmacotherapy added based on triglyceride levels and cardiovascular risk.

Causes of Hypertriglyceridemia

Hypertriglyceridemia is often multifactorial, with several potential causes:

Primary Factors:

• Genetic disorders affecting triglyceride metabolism

Secondary Factors:

• Dietary factors:

  • High intake of saturated fats
  • Excessive simple carbohydrates and added sugars
  • High fructose consumption (>100g/day)
  • Trans fats consumption 1
  • Excessive alcohol consumption

• Lifestyle factors:

  • Physical inactivity
  • Obesity, especially abdominal obesity
  • Rapid weight gain 1

• Medical conditions:

  • Diabetes mellitus
  • Metabolic syndrome
  • Hypothyroidism
  • Chronic liver or kidney disease
  • Nephrotic syndrome 2

• Medications:

  • Estrogens
  • Tamoxifen
  • Retinoids
  • Immunosuppressants
  • Beta-blockers
  • Thiazide diuretics 3

Classification of Triglyceride Levels

Triglyceride Level	Classification	Risk
<150 mg/dL	Normal	-
150-199 mg/dL	Borderline high	Increased cardiovascular risk
200-499 mg/dL	High	Increased cardiovascular risk
≥500 mg/dL	Very high	Risk of pancreatitis and cardiovascular disease
≥1,000 mg/dL	Severe	High risk of pancreatitis [1]

Management Approach

1. Lifestyle Modifications (First-Line for All Patients)

Weight management:

• Target 5-10% weight reduction, which can reduce triglycerides by approximately 20% 1
• Weight loss through caloric restriction is the most effective lifestyle intervention, potentially reducing TG levels by up to 50% 4

Dietary modifications:

• Reduce saturated fat to 7-10% of total calories
• Limit refined carbohydrates and added sugars to <6% of total daily calories
• Increase soluble fiber intake (10-25g/day)
• Add plant stanols/sterols (2g/day) 1
• Consider isocaloric substitution of nuts for other foods 4

Physical activity:

• Engage in at least 150 minutes per week of moderate-intensity aerobic activity or 75 minutes of vigorous activity
• Can reduce triglycerides by approximately 20% 1

Alcohol consumption:

• Restrict or eliminate alcohol consumption, particularly crucial for those with very high triglyceride levels 1
• Alcohol can significantly increase triglyceride levels, with nearly 1 in 5 hospitalized alcoholics having triglyceride levels exceeding 250 mg/dL 1

2. Pharmacological Management

For triglycerides 150-499 mg/dL with elevated cardiovascular risk:

• Statins are first-line therapy, providing 10-30% dose-dependent reduction in triglycerides 2
• For patients with 10-year ASCVD risk ≥7.5% to <20%, moderate-intensity statin therapy is recommended (Class IIa) 2
• For patients with 10-year ASCVD risk 5% to <7.5%, patient-clinician discussion regarding moderate-intensity statin therapy is recommended (Class IIb) 2

For triglycerides ≥500 mg/dL (to prevent pancreatitis):

• Fibrates (fenofibrate 54-160 mg daily) - can reduce triglycerides by 35-50% 3
  • Initial dose for severe hypertriglyceridemia: 54-160 mg per day
  • Maximum dose: 160 mg once daily
  • Dosage should be adjusted based on response at 4-8 week intervals 3
• Prescription omega-3 fatty acids (4g/day) - can reduce triglycerides by 25-35% (up to 45% with severe elevations) 1
• Icosapent ethyl 4g/day (2g twice daily with food) for patients with established cardiovascular disease or diabetes plus additional risk factors 2

For patients with established ASCVD and elevated triglycerides despite statin therapy:

• Consider adding icosapent ethyl 4g/day, which demonstrated a 25% relative risk reduction in cardiovascular events in the REDUCE-IT trial 2

3. Combination Therapy Considerations

• Statin plus fibrate: Generally not recommended as it has not been shown to improve ASCVD outcomes and increases risk of myositis and rhabdomyolysis 2
• Statin plus niacin: Generally not recommended as it has not been shown to provide additional cardiovascular benefit above statin therapy alone and may increase stroke risk 2

Monitoring

• Check lipid panels 4-8 weeks after initiating therapy
• Primary goal: Reduce triglycerides to <150 mg/dL
• For very high triglycerides: Immediate goal is to reduce levels to <500 mg/dL to prevent pancreatitis 1
• Monitor liver and renal function with pharmacological therapy, especially when using fibrates 1

Special Considerations

• Patients with diabetes should have glycemic control optimized, as improving glycemic control in diabetic patients with fasting chylomicronemia may obviate the need for pharmacologic intervention 3
• Identify and address secondary causes before or alongside pharmacologic therapy
• Consider referral to a registered dietitian nutritionist for individualized nutrition recommendations 2

By systematically addressing lifestyle factors and using appropriate pharmacotherapy based on triglyceride levels and cardiovascular risk, most patients can achieve significant improvements in their triglyceride levels and reduce their risk of complications.