What is the treatment for hypertriglyceridemia?

Treatment of Hypertriglyceridemia

The first-line treatment for hypertriglyceridemia is lifestyle modification, followed by pharmacotherapy with fibrates for severe hypertriglyceridemia (≥500 mg/dL) or statins for mixed dyslipidemia with cardiovascular risk. 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

Step 1: Lifestyle Modifications (All Patients)

• Dietary changes:
  • Low-fat diet (20-25% of total calories) 1
  • Increase dietary fiber to >10g/day 1
  • Reduce simple and refined carbohydrates 1
  • Eliminate added sugars 1
  • Limit or abstain from alcohol consumption 1
• Physical activity:
  • At least 150 minutes of moderate-intensity exercise per week 1
• Weight management for overweight/obese patients 1
• Address secondary causes:
  • Control diabetes mellitus
  • Treat hypothyroidism
  • Review medications that may elevate triglycerides (estrogen therapy, thiazide diuretics, beta-blockers) 2

Step 2: Pharmacotherapy Based on Triglyceride Levels

For Severe Hypertriglyceridemia (≥500 mg/dL):

• First-line: Fibrates (e.g., fenofibrate 54-160 mg/day) 1, 2

  • Initial dose: 54-160 mg/day with meals 2
  • Maximum dose: 160 mg once daily 2
  • Adjust dose every 4-8 weeks based on response 2
  • Monitor renal function before initiation, at 3 months, and every 6 months thereafter 1
  • Caution: Avoid in severe renal impairment 2

• Second-line: Omega-3 fatty acids (4 g/day) 1

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

• With elevated LDL-C or cardiovascular risk:

  • High-intensity statin therapy 1
  • Consider adding fibrate if triglycerides remain elevated despite statin therapy 1

• Without elevated LDL-C:

  • Continue lifestyle modifications
  • Consider fibrates if cardiovascular risk is high 1

Step 3: Management of Acute Hypertriglyceridemia-Induced Pancreatitis

For triglycerides >1000 mg/dL with pancreatitis:

• IV insulin therapy (0.1-0.3 units/kg/hr) with concurrent dextrose infusion 1
• Consider plasmapheresis when triglycerides remain significantly elevated despite insulin therapy 1
• Monitor triglyceride levels every 12-24 hours 1

Monitoring

• Monitor triglyceride levels every 4-8 weeks until stabilized, then every 3 months 1
• Target triglyceride level: <500 mg/dL to reduce pancreatitis risk 1
• For patients on fenofibrate: monitor lipid levels periodically and consider dose reduction if levels fall significantly below target 2
• Withdraw therapy if inadequate response after two months on maximum dose 2

Special Considerations

• Renal impairment: Start fenofibrate at 54 mg/day in mild to moderate renal impairment; avoid in severe renal impairment 2
• Elderly patients: Dose selection based on renal function 2
• Diabetes: Improving glycemic control may reduce triglycerides significantly 2
• Contraindications to fibrates:
  • Severe renal impairment
  • Active liver disease
  • Preexisting gallbladder disease
  • Nursing mothers
  • Known hypersensitivity to fenofibrate 2

Prevention of Recurrence

• Continue lifestyle modifications
• Regular monitoring of triglyceride levels
• Maintain optimal control of underlying conditions (diabetes, hypothyroidism)
• Avoid medications that can elevate triglycerides when possible 1

The treatment approach should be guided by the severity of hypertriglyceridemia and the presence of other cardiovascular risk factors, with the primary goals being prevention of pancreatitis in severe cases and reduction of cardiovascular risk in all patients.