What is the treatment for hypertriglyceridemia?

Treatment of Hypertriglyceridemia

The treatment of hypertriglyceridemia should begin with lifestyle modifications, followed by pharmacological therapy with fibrates as primary therapy for severe hypertriglyceridemia, and statins for patients with cardiovascular risk factors or mixed dyslipidemia. 1

Classification of Triglyceride Levels

Understanding the severity helps determine appropriate treatment:

• 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 1

Step 1: Lifestyle Modifications

Lifestyle modifications are the cornerstone of initial management:

• Diet modifications:

  • Very low-fat diet (<15% of total calories from fat) 1
  • For severe hypertriglyceridemia (≥1,000 mg/dL), extreme dietary fat restriction (<5% of total calories) until triglycerides are <1,000 mg/dL 2
  • Elimination of added sugars and alcohol 2, 1
  • Reduction in refined carbohydrates 1
  • Consumption of fatty fish twice weekly 1

• Physical activity:

  • 150 minutes/week of moderate-intensity aerobic activity (can reduce triglycerides by ~11%) 1

• Weight management:

  • Target 5-10% weight reduction (can reduce triglycerides by ~20%) 1

• Smoking cessation 1

Step 2: Address Secondary Causes

Identify and treat secondary causes of hypertriglyceridemia:

• Optimize glycemic control in diabetes 2, 1
• Discontinue medications that raise triglycerides (estrogens, tamoxifen, retinoids, immunosuppressants, beta-blockers) 1, 3
• Address alcohol consumption 1, 3
• Treat hypothyroidism if present 3

Step 3: Pharmacological Therapy

For Severe Hypertriglyceridemia (≥500 mg/dL):

1. Fibrates (First-line):

   • Fenofibrate 54-160 mg daily with meals 1, 3
   • Can reduce triglycerides by 35-54.5% 1, 3
   • Dosage should be individualized according to patient response 3
   • For patients with renal impairment, start at 54 mg daily 3

2. Prescription Omega-3 Fatty Acids (Add-on therapy):

   • 4g/day can reduce triglycerides by 25-35% (up to 45% with severe elevations) 1
   • The 2018 AHA/ACC guideline recommends prescription omega-3 fatty acids (IPE or omega-3 acid ethyl esters) if triglycerides remain elevated 2

For Mild to Moderate Hypertriglyceridemia with Cardiovascular Risk:

1. Statins:

   • Indicated when there's elevated LDL-C or cardiovascular risk 2, 1
   • Provide 10-30% dose-dependent reduction in triglycerides 1
   • Should be initiated or maximized if patients have diabetes mellitus or ASCVD 2

2. Combination Therapy:

   • If triglycerides remain elevated despite statin therapy, consider adding fibrates 1
   • Monitor for potential drug interactions when combining statins and fibrates

Monitoring and Follow-up

• Check lipid panels 4-8 weeks after initiating therapy 1
• Primary goal: Reduce triglycerides to <500 mg/dL to prevent pancreatitis 1
• Secondary goal: Achieve non-HDL cholesterol level 30 mg/dL higher than LDL goal 1
• Ultimate target: Reduce triglycerides to <150 mg/dL 1
• Monitor liver and renal function, especially when using fibrates 1

Special Considerations

• Fenofibrate should be given with meals to optimize bioavailability 3
• Avoid fibrates in patients with severe renal impairment 3
• Fibrates are contraindicated in patients with preexisting gallbladder disease 3
• Statins are contraindicated during pregnancy 1
• For patients with triglycerides ≥1,000 mg/dL, implement extreme dietary fat restriction (<5% of calories) until levels are <1,000 mg/dL to improve drug efficacy 2

Treatment Algorithm

1. For TG 150-499 mg/dL with cardiovascular risk:

   • Lifestyle modifications + statin therapy

2. For TG ≥500 mg/dL:

   • Lifestyle modifications + fibrate therapy (fenofibrate 54-160 mg daily)
   • Add prescription omega-3 fatty acids if needed

3. For TG ≥1,000 mg/dL:

   • Aggressive lifestyle modifications with extreme fat restriction (<5% of calories)
   • Fibrate therapy + consider omega-3 fatty acids
   • Monitor closely for pancreatitis risk

By following this approach, most patients with hypertriglyceridemia can achieve significant reductions in triglyceride levels, reducing their risk of pancreatitis and potentially cardiovascular disease.